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Chen Zhou ZH, Hilario A, Salvador Álvarez E, Cárdenas Del Carre A, Romero Coronado J, Lechuga C, Ramos González A. Radiological insights into rheumatoid meningitis - a rare central nervous system manifestation of rheumatoid arthritis: a retrospective review of six cases. Neurol Sci 2024; 45:4963-4971. [PMID: 38748074 DOI: 10.1007/s10072-024-07590-w] [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: 04/01/2024] [Accepted: 05/10/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND The objective is to analyze and review the clinical, laboratory, and neuroimaging characteristics of rheumatoid meningitis (RM) in six patients with known rheumatoid arthritis (RA). METHODS We performed a retrospective review of patients diagnosed with RM from August 2012 to June 2023. To identify the cases, we used medical term search engines and the hospital´s radiology case database. Clinical information and laboratory findings were gathered from the medical records. A neuroradiologist with five years of experience reviewed and analyzed the RM to determine the characteristics findings of RM. RESULTS Six patients with RM are included. Seizures along with headaches were among the clinical signs that were documented. All the patients had high levels of rheumatoid factor (RF) and anti-cyclic citrullinated peptides (ACPA) in the peripheral blood. Biopsy in two cases confirmed typical rheumatoid nodules. Leptomeningeal enhancement was found bilaterally in all cases and was predominantly found in the frontoparietal region. "Mismatch DWI/FLAIR" was found in five patients. Bilateral subdural collections could be found in two patients. Brain PET scan revealed increased metabolism in two cases. CONCLUSION Rheumatoid meningitis is a rare complication of rheumatoid arthritis (RA) with challenging clinical diagnosis due to non-specific symptoms. This study highlights the importance of MR in detecting characteristic neuroimaging patterns, including "mismatch DWI/FLAIR", to aid in early diagnosis. Increased awareness of this condition may facilitate timely intervention and improve prognosis. These results still need to be verified by large studies.
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Affiliation(s)
- Zhao Hui Chen Zhou
- Department of Radiology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain.
| | - Amaya Hilario
- Department of Radiology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain
| | - Elena Salvador Álvarez
- Department of Radiology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain
| | - Agustín Cárdenas Del Carre
- Department of Radiology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain
| | - Juan Romero Coronado
- Department of Radiology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain
| | - Carmen Lechuga
- Department of Radiology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain
| | - Ana Ramos González
- Department of Radiology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain
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2
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Brossard-Barbosa N, Donaldson L, Sokolova E, AlShafai L, Margolin E. Intracranial rheumatoid nodule causing recurrent transient neurological deficits. Pract Neurol 2023; 23:78-81. [PMID: 36198519 DOI: 10.1136/pn-2022-003489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 02/02/2023]
Abstract
A 67-year-old man with rheumatoid arthritis developed recurrent acute onset of stereotyped focal neurological abnormalities. Cerebral imaging showed a mass lesion in the left parieto-occipital lobe. Imaging did not show the time evolution expected in stroke and so he underwent an extensive workup, which was inconclusive. Brain biopsy identified a rheumatoid nodule causing an extensive inflammatory reaction that mimicked a mass. Following treatment with intravenous corticosteroids and rituximab infusions, his clinical condition improved. While rheumatoid meningitis is well recognised, a rheumatoid nodule in the brain rarely presents as a mass lesion. Nevertheless, it is important to consider rheumatoid nodule in the differential diagnosis of a cerebral mass lesion in patients with rheumatoid arthritis.
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Affiliation(s)
- Natalie Brossard-Barbosa
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Laura Donaldson
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Elena Sokolova
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
| | - Laila AlShafai
- Medical Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Edward Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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3
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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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4
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Audshasai T, Coles JA, Panagiotou S, Khandaker S, Scales HE, Kjos M, Baltazar M, Vignau J, Brewer JM, Kadioglu A, Yang M. Streptococcus pneumoniae Rapidly Translocate from the Nasopharynx through the Cribriform Plate to Invade the Outer Meninges. mBio 2022; 13:e0102422. [PMID: 35924840 PMCID: PMC9426477 DOI: 10.1128/mbio.01024-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/05/2022] [Indexed: 11/20/2022] Open
Abstract
The entry routes and translocation mechanisms of microorganisms or particulate materials into the central nervous system remain obscure We report here that Streptococcus pneumoniae (pneumococcus), or polystyrene microspheres of similar size, appear in the meninges of the dorsal cortex of mice within minutes of inhaled delivery. Recovery of viable bacteria from dissected tissue and fluorescence microscopy show that up to at least 72 h, pneumococci and microspheres were predominantly found in the outer of the two meninges: the pachymeninx. No pneumococci were found in blood or cerebrospinal fluid. Intravital imaging through the skull, aligned with flow cytometry showed recruitment and activation of LysM+ cells in the dorsal pachymeninx at 5 and 10 hours following intranasal infection. Imaging of the cribriform plate suggested that both pneumococci and microspheres entered through the foramina via an inward flow of fluid connecting the nose to the pachymeninx. Our findings bring new insight into the varied mechanisms of pneumococcal invasion of the central nervous system, but they are also pertinent to the delivery of drugs to the brain and the entry of airborne particulate matter into the cranium. IMPORTANCE Using two-photon imaging, we show that pneumococci translocate from the nasopharynx to the dorsal meninges of a mouse in the absence of any bacteria found in blood or cerebrospinal fluid. Strikingly, this takes place within minutes of inhaled delivery of pneumococci, suggesting the existence of an inward flow of fluid connecting the nasopharynx to the meninges, rather than a receptor-mediated mechanism. We also show that this process is size dependent, as microspheres of the same size as pneumococci can translocate along the same pathway, while larger size microspheres cannot. Furthermore, we describe the host response to invasion of the outer meninges. Our study provides a completely new insight into the key initial events that occur during the translocation of pneumococci directly from the nasal cavity to the meninges, with relevance to the development of intranasal drug delivery systems and the investigations of brain damage caused by inhaled air pollutants.
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Affiliation(s)
- Teerawit Audshasai
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Jonathan A. Coles
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Stavros Panagiotou
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Shadia Khandaker
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Hannah E. Scales
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Morten Kjos
- Faculty of Chemistry, Biotechnology and Food Science, Norwegian University of Life Sciences, Ås, Norway
| | - Murielle Baltazar
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Julie Vignau
- Centre de Recherche en Cancérologie et Immunologie Nantes Angers, Université de Nantes, Nantes, France
| | - James M. Brewer
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Aras Kadioglu
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Marie Yang
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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5
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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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6
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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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7
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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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8
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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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9
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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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10
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Pellerin D, Wodkowski M, Guiot MC, AlDhukair H, Blotsky A, Karamchandani J, Vinet E, Lafontaine AL, Lubarsky S. Rheumatoid Meningitis Presenting With Acute Parkinsonism and Protracted Non-convulsive Seizures: An Unusual Case Presentation and Review of Treatment Strategies. Front Neurol 2019; 10:163. [PMID: 30873111 PMCID: PMC6400852 DOI: 10.3389/fneur.2019.00163] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/07/2019] [Indexed: 11/26/2022] Open
Abstract
Rheumatoid meningitis is a rare complication of rheumatoid arthritis (RA). It is associated with substantial morbidity and mortality. The condition may present in a variety of ways and is therefore diagnostically challenging. Uncertainty still exists regarding the optimal treatment strategy. Herein, we describe the case of a 74-year-old man with a history of well-controlled seropositive RA on low-dose prednisone, hydroxychloroquine, and methotrexate. The patient presented with a several-month history of multiple prolonged episodes of expressive aphasia, right hemiparesis, and encephalopathy. Although no epileptiform activity was recorded on repeated electroencephalography, the symptoms fully resolved following treatment with antiepileptic drugs. He subsequently developed acute asymmetrical parkinsonism of the right hemibody. Magnetic resonance imaging revealed subtle enhancement of the leptomeninges over the left frontoparietal convexity. Cerebrospinal fluid analysis revealed a mild lymphocytic pleocytosis and elevated proteins. Histopathologic analysis of a meningeal biopsy revealed nodular rheumatoid meningitis. The patient was treated with corticosteroids and cyclophosphamide, following which he incompletely recovered. This is the first description of rheumatoid meningitis manifesting with acute parkinsonism and protracted non-convulsive seizures. A summary of cases reported since 2005, including data on pathology, therapy and outcomes, along with a discussion on the efficacy of different treatment strategies are provided.
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Affiliation(s)
- David Pellerin
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Michael Wodkowski
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Marie-Christine Guiot
- Department of Pathology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Hisham AlDhukair
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada.,Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Andrea Blotsky
- Division of General Internal Medicine, Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Jason Karamchandani
- Department of Pathology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Evelyne Vinet
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Anne-Louise Lafontaine
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Stuart Lubarsky
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada.,Centre for Medical Education, Faculty of Medicine, McGill University, Montreal, QC, Canada
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11
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McKenna MC, Vaughan D, Bermingham N, Cronin S. Rheumatoid arthritis presenting as rheumatoid meningitis. BMJ Case Rep 2019; 12:12/1/bcr-2018-226649. [PMID: 30635304 DOI: 10.1136/bcr-2018-226649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Rheumatoid meningitis (RM) is a rare extra-articular manifestation of rheumatoid arthritis (RA). A 59-year-old man presented with a 10-day history of right-sided frontal headache and a 7-day history of subacute left-sided weakness. He had no history of RA. He was febrile (38.2°C). Left ankle dorsiflexion and plantarflexion were graded at 4+/5. He developed focal onset motor seizures. He was intermittently febrile with minimal improvement despite intravenous antivirals and antimicrobials. Serology revealed elevated rheumatoid factor 88.2 IU/mL and anti-cyclic citrullinated peptide (anti-CCP) IgG >340 AU/mL. Initial cerebrospinal fluid (CSF) was predominantly lymphocytic 96%, with elevated protein 672 mg/L and normal glucose 3.4 mmol/L. Interval CSF revealed newly low glucose 2.6 mmol/L. Extensive CSF microbiology tests were negative. CSF cytology confirmed reactive lymphocytes. MRI brain revealed right frontoparietal leptomeningeal enhancement. Brain and leptomeningeal biopsy demonstrated florid leptomeningeal mixed inflammatory infiltrate without granulomas. The combination of elevated anti-CCP IgG, erosive arthropathy, CSF lymphocytosis, asymmetrical leptomeningeal enhancement and biopsy findings confirmed RM.
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Affiliation(s)
| | - David Vaughan
- Department of Neurology, Cork University Hospital, Cork, Ireland
| | - Niamh Bermingham
- Department of Neuropathology, Cork University Hospital, Cork, Ireland
| | - Simon Cronin
- Department of Neurology, Cork University Hospital, Cork, Ireland.,Department of Clinical Neuroscience, College of Medicine and Health, University College Cork, Cork, Ireland
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