223 - The “Trident Sign”: A Case Report Distinguishing Neurosarcoidosis from Other Myelopathies

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

SP

Sudeep Peddireddy, MD

Resident Physician
Temple University Health System
Philadelphia, Pennsylvania, United States

Co-Author(s)

NV

Noah T. VanWingerden, MD

Resident Physician
Temple University Hospital
Philadelphia, Pennsylvania, United States
GA

Glenn Adesoji, MD

Resident Physician
Temple University Hospital
Allentown, Pennsylvania, United States

Submitter(s)

SP

Sudeep Peddireddy, MD

Temple University Health System
Philadelphia, Pennsylvania, United States

Case Diagnosis: Longitudinally extensive transverse myelitis (LETM) in setting of systemic sarcoidosis

Case Description: This case describes a 58 year old male with biopsy-proven sarcoidosis who presented to clinic with uveitis, urinary incontinence, and gait abnormality from lower extremity weakness. He subsequently underwent an outpatient magnetic resonance imaging (MRI) of his cervical spine, which noted diffuse spinal cord edema, at which point he was admitted directly to inpatient neurology. Further review of the outpatient MRI demonstrated superimposed multifocal patchy T1-weighted post-contrast enhancement of the dorsal tracts, forming a “trident sign.” He was ultimately diagnosed with neurosarcoidosis induced LETM. Initial treatment included a steroid taper and methotrexate, but is now being considered for infliximab given ongoing weakness and gait dysfunction.

Discussions: In this case of a 58-year-old-male found to have multi-system involvement of sarcoidosis, the first sign on imaging prior to any subsequent work-up was the trident sign observed on outpatient MRI of the cervical spine. Neurosarcoidosis is a difficult condition to diagnose with many differential diagnoses of overlapping clinical presentation. It is important to differentiate between these diagnoses as the treatments can vary widely. The trident sign has a specificity of 89% in neurosarcoidosis as reported by Zalewski et al, and it can be a key differentiator when assessing a broad list of differentials for myelopathy including compressive lesions, spinal cord infarctions, transverse myelitis, vitamin deficiencies, infectious sequelae, etc.

Conclusions: This case illustrates the diagnostic challenge of neurosarcoidosis presenting as longitudinally extensive transverse myelitis. Recognition of the trident sign on spinal MRI proved pivotal in raising suspicion for neurosarcoidosis, a finding with high specificity that aids in distinguishing it from other etiologies of LETM. Early identification of characteristic imaging features may guide treatment options and optimize functional outcomes.