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Yang J, Liu L, Peng J, Ma B, Yang X. Rheumatoid meningitis in the absence of rheumatoid arthritis: 2 cases. BMC Neurol 2024; 24:243. [PMID: 39009960 PMCID: PMC11247829 DOI: 10.1186/s12883-024-03751-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024] Open
Abstract
Rheumatoid meningitis (RM) is a rare extra-articular manifestation of rheumatoid arthritis (RA) that has been increasingly recognized by neurologists. However, the diversity of its clinical manifestations makes its diagnosis difficult. RM does not have a unified diagnostic standard, and its link with RA needs to be studied further. Here we report two cases of RM without a history of RA. The first patient, an 80-year-old woman, presented with sudden unilateral limb weakness, with brain MR showing abnormal signals in the leptomeningeal of the right frontal parietal. Subarachnoid hemorrhage was excluded after imaging examination, and infectious meningitis was ruled out after cerebrospinal fluid (CSF) examination. The patient was diagnosed as having RM, she had increased levels of CCP and AKA, the markers of RA, but no history of the disease or other clinical manifestations of it. Another case, a 65-year-old man, was hospitalized with Bell's palsy. We found that he had intracranial imaging changes highly consistent with those characteristic of RM during his routine examination. Except for the left peripheral facial palsy, the patient had no other neurological signs or symptoms and no RA history. After a careful physical examination, we found no joint or other manifestations or serological abnormalities consistent with RA (RF, CCP, AKA, etc.). However, after excluding infection meningitis and considering the patient's unique imaging results, we diagnosed him as having RM. We report these two cases as references for clinical diagnosis and treatment of RM, providing a discussion of our rationale.
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Affiliation(s)
- Juan Yang
- Department of Neurology, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing District, Ningxia, Yinchuan, 750000, China
| | - Lu Liu
- Department of Neurology, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing District, Ningxia, Yinchuan, 750000, China
| | - Jiahui Peng
- Department of Neurology, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing District, Ningxia, Yinchuan, 750000, China
| | - Boya Ma
- Department of Neurology, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing District, Ningxia, Yinchuan, 750000, China
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing District, Ningxia, Yinchuan, 750000, China.
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2
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Murakami K, Miyamoto K, Koh J, Kajimoto Y, Ito H. Three-year follow-up of rheumatoid meningitis with matrix metalloprotease-9 levels in the serum and cerebrospinal fluid as indicators of disease activity: A case report. J Neuroimmunol 2024; 390:578331. [PMID: 38552529 DOI: 10.1016/j.jneuroim.2024.578331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 05/13/2024]
Abstract
Rheumatoid meningitis (RM) is an extra-articular complication of rheumatoid arthritis (RA). Although reports of RM sine arthritis exist, most patients with this presentation were diagnosed with RA within one year of RM onset. There are no established biomarkers reflecting the disease activity of RM. This case report highlights the elevation of matrix metalloprotease (MMP)-9 levels during the acute phase of RM and decline during remission. Additionally, this is the first case report of RA diagnosed three years after the onset of RM. It is important to further validate the utility of MMP-9 and conduct long-term follow-up of RM sine arthritis.
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Affiliation(s)
- Keishu Murakami
- Department of Neurology, Wakayama Medical University, Wakayama, Japan.
| | | | - Jinsoo Koh
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
| | | | - Hidefumi Ito
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
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3
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Beppu S, Yabumoto T, Kinoshita M, Okuno T, Todo K, Tani N, Kishima H, Motoyama Y, Morii E, Mochizuki H. [Does 'IgG4-related leptomeningitis' exist?]. Rinsho Shinkeigaku 2022; 62:954-955. [PMID: 36450493 DOI: 10.5692/clinicalneurol.cn-001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shohei Beppu
- Department of Neurology, Osaka University Graduate School of Medicine
| | - Taiki Yabumoto
- Department of Neurology, Osaka University Graduate School of Medicine
| | - Makoto Kinoshita
- Department of Neurology, Osaka University Graduate School of Medicine
| | - Tatsusada Okuno
- Department of Neurology, Osaka University Graduate School of Medicine
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine
| | - Naoki Tani
- Department of Neurosurgery, Osaka University Graduate School of Medicine
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine
| | - Yuichi Motoyama
- Department of Pathology, Osaka University Graduate School of Medicine
| | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine
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Huang G, Wu L, Mei Z, Yao D. Rheumatoid meningitis without a history of rheumatoid arthritis: a case report and literature review. Rheumatol Int 2022; 43:1173-1182. [PMID: 36125522 DOI: 10.1007/s00296-022-05209-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022]
Abstract
Rheumatoid meningitis (RM) is a rare extra-articular manifestation of rheumatoid arthritis, usually with non-specific symptoms. In most cases, head magnetic resonance imaging (MRI) shows lamellar enhancements in leptomeninges and pachymeninges, but definitive diagnosis relies on meningeal biopsies. Here, we reported a 43-year-old RM patient without a previous history of rheumatoid arthritis. He came to seek medical assistance because of fever and headache. The head MRI showed bilateral enhancements in leptomeninges and pachymeninges, and blood tests showed that serum IgM rheumatoid factor (RF) (1010.0 IU/ml) and anti-cyclic citrullinated peptide (CCP) antibody (654.24 RU/ml) became positive with a further increase with the progression of the disease. After treatment with steroids, clinical symptoms were relieved. We also reviewed previous history, symptoms, and serum, cerebrospinal fluid and imaging findings in 15 RM cases without a history of rheumatoid arthritis published since 2010. Consistent with previous reported cases, the current case suggests importance of meningeal biopsies and increases in serum RF and anti-CCP antibody in diagnosis of RM. In addition, previous joint symptoms and chronic headaches, and leptomeningeal and pachymeningeal lesions on head MRI are also of great significance for the diagnosis.
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Affiliation(s)
- Gang Huang
- Neurological Institute of Jiangxi Province and Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang Medical College, 92 Aiguo Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Lingfeng Wu
- Neurological Institute of Jiangxi Province and Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang Medical College, 92 Aiguo Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Zhujun Mei
- Neurological Institute of Jiangxi Province and Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang Medical College, 92 Aiguo Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Dongyuan Yao
- Neurological Institute of Jiangxi Province and Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang Medical College, 92 Aiguo Road, Nanchang, 330006, Jiangxi, People's Republic of China.
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5
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Chirila RM, Berianu F, Abril A, Butendieck RR. Extra-articular involvement of rheumatoid arthritis in three seropositive patients in the absence of initial joint involvement. Immun Inflamm Dis 2021; 9:1613-1617. [PMID: 34473908 PMCID: PMC8589363 DOI: 10.1002/iid3.514] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Extra‐articular involvement (EAI) in rheumatoid arthritis (RA) is rare, severe and usually presents after years of joint involvement. Onset of RA as lung involvement has been published. We describe a series of three patients with strongly positive anti‐citrullinated peptide antibodies (ACPA) and rheumatoid factor (RF) positive in the absence of joint symptoms, but with significant EAI. Methods This is a descriptive case series of three patients evaluated in an academic medical center rheumatology clinic. Results A 50‐year‐old female presented with severe recurrent scleritis in the background of strongly positive ACPA, but no joint involvement. Her ocular disease responded well to rituximab. Four years later, she developed peripheral inflammatory arthritis consistent with RA. A 74‐year‐old male presented after developing recurrent steroid‐dependent serositis (pleuro‐pericarditis) and interstitial lung disease (ILD). Serology was notable for strongly positive ACPA, but no joint involvement. Serositis responded well to adalimumab. Two years after initial symptoms, he developed peripheral joint involvement after holding adalimumab. A 56‐year‐old female presented with an isolated, biopsy‐proven subcutaneous rheumatoid nodule. Subsequently, she developed pancytopenia and fatigue. She tested strongly positive for ACPA and RF. Bone marrow biopsy was negative for malignancy and she had no evidence of infection. She responded to steroids and hydroxychloroquine and had not developed joint involvement after 2 years of follow‐up. Conclusion EAI as an onset of RA is a complex and not easily recognized entity if typical joints involvement is not yet present. Early diagnosis may help guide specific therapy and prevent sequelae and co‐morbidities.
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Affiliation(s)
- Razvan M Chirila
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, Florida, USA
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Galetta K, Bhattacharyya S. Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases. Semin Neurol 2021; 41:541-553. [PMID: 34619780 DOI: 10.1055/s-0041-1733790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.
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Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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Villa E, Sarquis T, de Grazia J, Núñez R, Alarcón P, Villegas R, Guevara C. Rheumatoid meningitis: A systematic review and meta-analysis. Eur J Neurol 2021; 28:3201-3210. [PMID: 33966315 DOI: 10.1111/ene.14904] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Rheumatoid meningitis (RM) is a neurological complication of rheumatoid arthritis (RA). Current evidence is based on case reports and partial reviews. METHODS This is a systematic review and meta-analysis following the PRISMA statement. The aim is to describe the characteristics of the disease, including clinical, imaging and laboratory findings, treatment, outcomes and prognosis reported in the literature. RESULTS In all, 103 studies with 130 cases were included. RM affected adults with an average age of 62 years, with or without a previous RA diagnosis. RA activity and time with the disease were associated with a worse prognosis. Most common clinical manifestations were transient focal neurological signs (64.6%), systemic symptoms (51.3%), episodic headache (50.4%) and neuropsychiatric alterations (47.7%). Joint manifestations were present in only 27.4% of cases. Brain magnetic resonance imaging showed unilateral or bilateral involvement, predominantly frontoparietal. Both pachymeninges and leptomeninges were affected, the latter more frequently (82.88%). The laboratory findings included increased levels of rheumatoid factor (89.71%), anti-cyclic citrullinated peptide (89.47%), C-reactive protein (82.54%) and erythrocyte sedimentation rate (81.81%). Cerebrospinal fluid analysis showed an increase in the protein level (76.14%), with pleocytosis (85.19%) of mononuclear predominance (89.19%). Biopsy was performed in 72.52% of the patients. Corticosteroid pulse therapy was the main induction therapy. Disease relapse occurred in 31.17% of patients, whilst 54.54% had a full recovery. CONCLUSIONS Rheumatoid meningitis must be considered in adult patients with or without RA diagnosis, high-dose corticosteroid induction therapy should be installed and maintenance therapy plays a key role. It is not recommended to use anti-TNF as an induction therapy. Nowadays, RM has a significantly better outcome. These findings may aid clinicians in timely RM diagnosis and treatment, thus improving its outcomes.
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Affiliation(s)
- Eduardo Villa
- Department of Neurology and Neurosurgery, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Teresita Sarquis
- Department of Neurology and Neurosurgery, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - José de Grazia
- Department of Radiology, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - René Núñez
- Department of Radiology, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Pablo Alarcón
- Genetic Section, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Rodrigo Villegas
- Program in Biostatistics, School of Public Health, Universidad de Chile, Santiago, Chile
| | - Carlos Guevara
- Department of Neurology and Neurosurgery, Faculty of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
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8
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Zhang Z, Pan T, Liu C, Shan X, Xu Z, Hong H, Lin H, Chen J, Sun H. Cyclophosphamide induced physiological and biochemical changes in mice with an emphasis on sensitivity analysis. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2021; 211:111889. [PMID: 33461014 DOI: 10.1016/j.ecoenv.2020.111889] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/21/2020] [Accepted: 12/31/2020] [Indexed: 06/12/2023]
Abstract
The widespread use of cyclophosphamide (CP) in medical treatment had caused ubiquitous contamination in the environment. To data, many studies have been carried out on the toxic effect of CP. However, among these toxic effects of CP, which are the most sensitive remains unclear. Present study aimed to investigate the toxicity of CP on mice and evaluate the sensitivity of physiological-biochemical parameters upon exposure of mice to CP. Results showed that as compared with the control group, CP caused significant reduction in body weight (p < 0.01), spleen coefficient (p < 0.01), leukocyte density (p < 0.01) and alanine transaminase (ALT) in kidney (p < 0.01); However superoxide dismutase (SOD), malondialdehyde (MDA), ALT in liver and creatinine (Cr) in kidney significantly (p < 0.05) increased. Among the suppressed physiological and biochemical parameters, the sensitivity to CP toxicity was generally ranked as body weight > leukocyte density > ALT in kidney > spleen coefficient; while among the stimulated parameters, the sensitivity was ranked as MDA (liver) > Cr (kidney) > ALT (liver). Overall, the most sensitive parameters to CP toxicity may be associated with growth, immune system and the normal function of liver and kidney.
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Affiliation(s)
- Zhiying Zhang
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China
| | - Ting Pan
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China
| | - Chunrong Liu
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China
| | - Xiaoyun Shan
- Jinhua Municipal Central Hospital, Jinhua, China
| | - Zeqiong Xu
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China
| | - Huachang Hong
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China.
| | - Hongjun Lin
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China
| | - Jianrong Chen
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China; Jinhua Municipal Central Hospital, Jinhua, China
| | - Hongjie Sun
- College of Geography and Environmental Science, Zhejiang Normal University, Jinhua, China.
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9
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Miyaue N, Yabe H, Yamanishi Y, Tada S, Ando R, Nagai M. Three cases of rheumatoid meningitis with elevated CSF neopterin levels. J Neuroimmunol 2020; 348:577396. [PMID: 32971299 DOI: 10.1016/j.jneuroim.2020.577396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023]
Abstract
Rheumatoid meningitis (RM) is a rare but treatable central nervous system (CNS) manifestation of rheumatoid arthritis (RA) with various clinical presentations and atypical cerebrospinal fluid (CSF) findings. There are no established biomarkers for RM, making diagnosis a challenge. Herein, we present three cases of RM: two patients with RA diagnosis and one without. CSF analysis showed pleocytosis in only one case. In contrast, CSF neopterin levels were elevated in all three cases and decreased after steroid therapy. This study suggests that CSF neopterin levels may be a useful biomarker for diagnosing and therapeutically monitoring CNS inflammation in patients with RM.
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Affiliation(s)
- Noriyuki Miyaue
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Tohon, Ehime, Japan; Department of Neurology, Saiseikai Matsuyama Hospital, Matsuyama, Ehime, Japan.
| | - Hayato Yabe
- Department of Neurology, Saiseikai Matsuyama Hospital, Matsuyama, Ehime, Japan
| | - Yuki Yamanishi
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Tohon, Ehime, Japan
| | - Satoshi Tada
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Tohon, Ehime, Japan
| | - Rina Ando
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Tohon, Ehime, Japan
| | - Masahiro Nagai
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Tohon, Ehime, Japan
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10
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Rodriguez Alvarez M, Rodríguez Valencia LM, Seidman R, Acharya A, Espina N, Ravindran N, Mishan D, Mesa CJ, Espinoza LR, McFarlane IM. Rheumatoid meningitis and infection in absence of rheumatoid arthritis history: review of 31 cases. Clin Rheumatol 2020; 39:3833-3845. [PMID: 32519051 DOI: 10.1007/s10067-020-05221-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 12/17/2022]
Abstract
A 62-year-old healthy male presents with leg weakness and fever. Imaging revealed leptomeningeal enhancement (LE). After cerebrospinal fluid (CSF) cultures were negative, he was discharged with a diagnosis of aseptic meningitis, but was readmitted due to worsening symptoms. Brain biopsy suggested rheumatoid leptomeningitis associated with elevated serum rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibodies (ACPA). Following discharge, the New York State Department of Health (NYSDOH) reported a polymerase chain reaction (PCR) on CSF and brain DNA consistent with Naegleria fowleri (NF). After dramatic improvement on steroids, the patient declined antimicrobial treatment. Upon prednisone taper, symptoms recurred which responded to rituximab (RTX). This case highlights a possible association between rheumatoid leptomeningitis (RM) onset and infection, in a patient without a history of rheumatoid arthritis (RA). Our goal is to assess whether this association is present in 69 RM cases reported since 2000. We also describe diagnosis and treatment of 31 new cases (January 2017 to March 2020). We did not identify evidence of active/latent infection in patients with RM and previous RA; however, patients without RA history appeared to have a significantly higher rate. This finding could demonstrate the necessity of evaluating for infection in de novo RM cases without antecedent RA history. We also describe characteristic clinical patterns for each group. More studies are needed to corroborate these results and expand into a possible distinct natural history of RM in each group, which might have an impact upon the clinical outcome.
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Affiliation(s)
- Milena Rodriguez Alvarez
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA. .,School of Graduate Studies, SUNY-Downstate Medical Center, Brooklyn, NY, 11203, USA.
| | | | - Roberta Seidman
- Department of Pathology, Stony Brook University Hospital, Stony Brook, NY, 11794, USA
| | - Ajita Acharya
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA
| | - Noel Espina
- Department of Health, Wadsworth Center, New York State, Albany, NY, 12237, USA
| | - Nadish Ravindran
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA
| | - Daniel Mishan
- School of Graduate Studies, SUNY-Downstate Medical Center, Brooklyn, NY, 11203, USA
| | - Christopher J Mesa
- Department of Internal Medicine, Division of Rheumatology, Louisiana State University Health Science Center New Orleans, New Orleans, LA, 70006, USA
| | - Luis R Espinoza
- Department of Internal Medicine, Division of Rheumatology, Louisiana State University Health Science Center New Orleans, New Orleans, LA, 70006, USA
| | - Isabel M McFarlane
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA
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Rheumatoid arthritis with pachymeningitis - a case presentation and review of the literature. Reumatologia 2020; 58:116-122. [PMID: 32476685 PMCID: PMC7249520 DOI: 10.5114/reum.2020.95368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/09/2020] [Indexed: 11/17/2022] Open
Abstract
Rheumatoid meningitis (RM) is a rare central nervous system (CNS) manifestation of rheumatoid arthritis (RA) with a wide spectrum of symptoms. We present a review of the literature with a rare illustrative case of a 61-year-old man with a history of seropositive rheumatoid arthritis (RA) who presented headaches, stroke-like symptoms and seizures. MRI revealed the leptomeningeal enhancement in the right hemisphere. As cerebromeningeal fluid showed increased level of protein and was positive for Candida mannan, the initial clinical diagnosis was fungal meningitis. Despite the antifungal treatment the patient’s clinical condition did not improve. Detailed laboratory, radiologic and histopathological diagnostics enabled the diagnosis of RM. In conclusion is worth to highlight that presentation of RM is variable and complex, diagnosing it is a big dilemma which is why it must be considered in the differential in a patient with long-standing seropositive RA.
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12
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Abussuud ZA, Geneta VP. Rheumatoid Meningitis. World Neurosurg 2020; 137:98-101. [PMID: 32035199 DOI: 10.1016/j.wneu.2020.01.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Rheumatoid meningitis is a rare manifestation of autoimmune rheumatoid arthritis. CASE DESCRIPTION A 70-year-old man with rheumatoid arthritis had presented with speech difficulties and limb weakness. Magnetic resonance imaging of his brain demonstrated diffuse meningeal enhancement. A biopsy confirmed the presence of rheumatoid meningitis. CONCLUSION In the present report, we have discussed the diagnostic and therapeutic approach to rheumatoid meningitis.
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Affiliation(s)
- Zeid A Abussuud
- Department of Neurosurgery, Wellington Regional Hospital, Wellington, New Zealand.
| | - Von Paolo Geneta
- Department of Neurosurgery, Wellington Regional Hospital, Wellington, New Zealand
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13
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Nissen MS, Nilsson AC, Forsberg J, Milthers J, Wirenfeldt M, Bonde C, Byg KE, Ellingsen T, Blaabjerg M. Use of Cerebrospinal Fluid Biomarkers in Diagnosis and Monitoring of Rheumatoid Meningitis. Front Neurol 2019; 10:666. [PMID: 31293505 PMCID: PMC6606769 DOI: 10.3389/fneur.2019.00666] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/06/2019] [Indexed: 12/27/2022] Open
Abstract
Rheumatoid meningitis is a rare extra-articular manifestation of rheumatoid arthritis, often with non-specific symptoms. In most cases brain MRI shows a patchy lepto- and pachymeningeal enhancement, but the diagnosis currently relies on examination of a meningeal biopsy with presence of plasma cells and rheumatoid noduli. Presence of IgM rheumatic factor (RF) has been found in several cases and recently four cases have shown high titer anti-cyclic citrullinated peptide (anti-CCP) in CSF, suggesting this as a potential marker for rheumatoid meningitis. We present a 62 year-old woman with sero-positive (IgM RF and anti-CCP) rheumatoid arthritis, presenting with headache and gait impairment. Brain MRI revealed the classical patchy meningeal enhancement and the diagnosis of rheumatoid meningitis was confirmed by neuropathological examination of a meningeal biopsy. Analysis of the CSF revealed positive IgM RF (92.7 IU/mL) and strongly positive anti-CCP (19,600 IU/mL) and CXCL-13 (>500 ng/L). After treatment with high-dose steroid and Rituximab the clinical symptoms resolved. A 6 month follow-up analysis of CSF showed a dramatic decrease in all these markers with negative IgM RF and a decrease in both anti-CCP (64 IU/mL) and CXCL-13 (<10 ng/L). Our case further underlines the potential use of CSF anti-CCP and IgM RF in the diagnosis of RM and the use of these markers and CXCL-13 in evaluation of treatment response. A case review of 48 cases of rheumatoid meningitis published since 2010, including, symptoms, serum, and CSF findings, treatment, and outcome is provided.
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Affiliation(s)
- Mette Scheller Nissen
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Jonatan Forsberg
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Jesper Milthers
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Martin Wirenfeldt
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Christian Bonde
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Keld-Erik Byg
- The Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Torkell Ellingsen
- The Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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