Acute monocular visual loss in carcinomatous hypertrophic pachymeningitis mimicking giant cell arteritis

Hypertrophic pachymeningitis associated with antineutrophil cytoplasmic antibody-associated vasculitis: a case series of 15 patients

OBJECTIVE

We aimed to describe the clinical characteristics and treatment course of hypertrophic pachymeningitis (HPM) in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

We retrospectively analysed 15 patients (11 men and four women). HPM was diagnosed based on thickening and enhancing of the brain and/or spinal dura mater on gadolinium-enhanced magnetic resonance imaging (MRI) T1 sequence.

RESULTS

The median age at HPM onset was 60 years. Headache and cranial nerve impairment were observed in 14 and 10 patients, respectively. Otitis media and/or mastoiditis were found as complications of AAV in 11 patients. Fourteen patients were classified as having granulomatosis with polyangiitis (GPA). Single-positive myeloperoxidase-ANCA, single-positive proteinase 3-ANCA, and double-positive ANCA were identified in seven patients, five patients, and one patient, respectively. With MRI, thickening of the dura mater in the cranial fossa and tentorium cerebelli was found in 10 and eight patients, respectively. For remission induction, all patients were treated with corticosteroids, and immunosuppressants were added in 10 patients. Dura mater thickening partially improved in all patients, and cranial neuropathy completely remitted in eight patients. In a median follow-up of 43 months, four patients had HPM relapse and underwent reinduction therapy. All six patients treated with cyclophosphamide at initial therapy did not relapse.

CONCLUSIONS

HPM was mostly associated with patients with GPA with otitis media and/or mastoiditis having either type of ANCA serology. Treatment with corticosteroids with or without immunosuppressants was effective. However, HPM relapse occasionally occurred, especially when cyclophosphamide was not used in initial treatment.

Vision loss in tuberculous meningitis

Vision loss is a disabling complication of tuberculous meningitis. Approximately, 15% of survivors are either completely or partially blind. All structures of the visual pathway may be affected in tuberculous meningitis. Optic nerve and optic chiasma are most frequently and dominantly affected. Thick-gelatinous exudates lying over the base of brain, are the pathological hallmark of tuberculous meningitis and are responsible for almost all of its major complications, including vision loss. Strangulation of optic nerves and optic chiasma by the exudates, compression over optic chiasma by the dilated third ventricle, raised intracranial pressure, endarteritis, shunt failure, bacterial invasion of optic nerves and drug-induced optic nerve damage are important reasons that are considered responsible for vision loss. Prompt antituberculosis treatment is the best management option available. Immunomodulatory drugs and cerebrospinal fluid diversion procedures are of limited help. Early recognition and treatment of tuberculous meningitis is the only way forward to tackle this problem.