Preliminary Study of the Possible Benefit of the Reversible Acetylcholinesterase Inhibitor Donepezil for Cognitive Impairment Associated with Corticorticosteroid Treatment for Presumptive Neurosarcoidsosis with a Lesion in the Right Basal Ganglia and Thalamus

Aims: To present the case of a patient diagnosed by neurology with neurosarcoidsosis with cognitive impairment after long-term treatment with corticosteroids who showed marked improvement in his cognition upon initiation of donepezil. To provide a brief overview of the treatment of neurosarcoidosis and corticosteroid-induced cognitive disorders with acetylcho-linesterase inhibitors and clarify any literature regarding the use of acetylcholinesterase inhibitors in neurosarcoidosis.

Presentation of Case:  G.A. was a 46-year-old African American veteran who spent 14 years in the Army as a Patriot Missile Crewmember. He was exposed to active combat and ionizing radiation in the gulf and suffered from Posttraumatic Stress Disorder (PTSD) and Recurrent Major Depressive Disorder Moderate (MDD). Eight years after retirement he presented with transient visual symptoms and left-sided focal facial and lower extremity weakness. Neurosarcoidosis was diagnosed by his neurologist who identified a lesion in his right basal ganglia and thalamus on MRI. He was treated with corticosteroids for 8-9 years and referred for psychiatric evaluation 1 year after cessation of corticosteroids. He reported persisting slowed thinking, impaired memory and slow reaction times. Neuropsychological testing done 1 year after diagnosis was repeated 3 years later and showed little change. He had been treated with sertraline 200 mg daily for PTSD and MDD. Donepezil 5 mg at bedtime was added and after 2 months he reported marked improvement. Donepezil was increased to 10 mg and after 1 week his thinking returned to normal and he had no complaints. His wife confirmed his history. He was thinking more clearly; his recall and reaction time were improved and he felt more confident in himself. Follow-up neuropsychological testing is planned in 12 months.

Discussion: There are no reports of the use of acetylcholinesterase inhibitors in the treatment of neurosarcoidosis.

Conclusion: The use of donepezil for the treatment of corticosteroid-induced cognitive impairment in neurosarcoidsosis deserves further investigation.