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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 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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Khan O, Aslam S, Mohammadrezaei F, Wilches RDM, Mehrabi J, Yehounatan M, Kumari S, Singh S, Ahmadi M, Masri D, Konka S, Margulis Y. New-onset seizures: an unusual neurologic manifestation of rheumatoid arthritis. Oxf Med Case Reports 2024; 2024:omad159. [PMID: 38370505 PMCID: PMC10873692 DOI: 10.1093/omcr/omad159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/16/2023] [Accepted: 12/08/2023] [Indexed: 02/20/2024] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory condition primarily affecting the musculoskeletal system but can often involve other organ systems as well. Rheumatoid meningitis is a rare central nervous system (CNS) manifestation of RA characterized by pachymeningeal and leptomeningeal enhancement. Herein, we present a case of a 64-year-old male who presented with left lower extremity weakness and witnessed seizures. The diagnostic work-up, including lumbar puncture, brain MRI and meningeal biopsy ruled out malignancy and were consistent with the diagnosis of rheumatoid meningitis. The patient was discharged on high-dose steroids along with anti-seizure medications. On subsequent follow-up visits, the patient remained seizure-free.
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Affiliation(s)
- Omair Khan
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Sadia Aslam
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | | | | | - Joseph Mehrabi
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | | | - Sapna Kumari
- Department of Medicine, Ross University School of Medicine, Bridgetown, Barbados
| | - Sehajpreet Singh
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Maryam Ahmadi
- Department of Pathology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Daniel Masri
- Department of Radiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Sarita Konka
- Division of Rheumatology, Maimonides Medical Center, Brooklyn, NY, USA
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3
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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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4
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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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5
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Manolios E, Manolios N, Spencer D. Leptomeningitis in rheumatoid arthritis. Eur J Rheumatol 2020; 8:48-50. [PMID: 33044165 DOI: 10.5152/eurjrheum.2020.20063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/03/2020] [Indexed: 11/22/2022] Open
Abstract
In this case report, we describe the case of a patient given the presumptive diagnosis of rheumatoid leptomeningitis on the basis of clinical findings and clinical response to antirheumatic medications after other causes of meningitis were excluded. Numerous case reports describe rheumatoid meningitis; however, rheumatoid leptomeningitis, in the absence of pachymeningitis, is a rare phenomenon. As such, the literature about it is scant. This unique case provides an opportunity to further characterize the symptoms and radiological findings of leptomeningitis in a patient with rheumatoid arthritis.
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Affiliation(s)
- Emmanuel Manolios
- Faculty of Medical and Allied Health, The University of Sydney Northern Clinical School, Sydney, Australia
| | - Nicholas Manolios
- Faculty of Medical and Allied Health, The University of Sydney Northern Clinical School, Sydney, Australia.,Department of Rheumatology, Westmead Hospital, Westmead, Sydney
| | - David Spencer
- Faculty of Medical and Allied Health, The University of Sydney Northern Clinical School, Sydney, Australia.,Department of Rheumatology, Westmead Hospital, Westmead, Sydney
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6
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Abdullah HMA, Omar M, Jbeli A, Fanciullo J. Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis. BMJ Case Rep 2019; 12:12/12/e231474. [PMID: 31822530 DOI: 10.1136/bcr-2019-231474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.
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Affiliation(s)
| | - Muhammad Omar
- Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
| | - Aiham Jbeli
- Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
| | - Joseph Fanciullo
- Rheumatology, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
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7
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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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8
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Lee Ching C, Kenyon L, Berk M, Park C. Rheumatoid meningitis sine arthritis. J Neuroimmunol 2019; 328:73-75. [DOI: 10.1016/j.jneuroim.2018.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/02/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022]
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9
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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: 16] [Impact Index Per Article: 3.2] [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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10
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Harrison NS, Kishore S, Majithia V. Rheumatoid meningitis: successful remission with rituximab. BMJ Case Rep 2018; 11:11/1/e226642. [PMID: 30598469 DOI: 10.1136/bcr-2018-226642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 53-year-old male with rheumatoid arthritis presented with recurrent headaches, seizures and right-sided lower extremity paralysis while on antiepileptic medications. Work up revealed pachymeningeal and leptomeningeal enhancement on brain MRI. Differential diagnosis included a variety of infections, neoplasm and vasculitis. Histopathology showed findings consistent with rheumatoid meningitis (RM). Ultimately based on symptoms, MRI findings and tissue pathology, he was diagnosed with RM. Intravenous pulse dose steroids were initiated followed by rituximab every 6 months, resulting in significant improvement of the brain MRI findings. Patient has remained seizure free.
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Affiliation(s)
- Nancy Salloum Harrison
- Department of Rheumatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Shweta Kishore
- Department of Rheumatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Vikas Majithia
- Department of Rheumatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
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11
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Affiliation(s)
- Alair Sarmet Santos
- Associate Professor in the Department of Radiology of the Fluminense Federal University School of Medicine, Head of the Radiology Department of the Antônio Pedro University Hospital, Niterói, RJ, Brazil
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12
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TINIAKOU ELENI, KONTZIALIS MARINOS, PETRI MICHELLE. Rheumatoid Pachymeningitis: A Rare Complication of Rheumatoid Arthritis. J Rheumatol 2018; 45:1325-1326. [DOI: 10.3899/jrheum.171074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Oono M, Fujita Y, Uchida N, Kawai U, Fujita-Nakata M, Nakanishi M, Sanada M, Nagayama S, Matsui M. Rheumatoid meningitis developed in patient with stable rheumatoid arthritis and myasthenia gravis-detailed analysis of intracranial inflammation using flow cytometry. J Neuroinflammation 2018; 15:151. [PMID: 29776427 PMCID: PMC5960130 DOI: 10.1186/s12974-018-1196-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/10/2018] [Indexed: 11/29/2022] Open
Abstract
Background Rheumatoid meningitis (RM) is a rare disorder that often develops during a remission phase of rheumatoid arthritis (RA). This is the first study to demonstrate differences in regard to immunological disturbance between blood and cerebrospinal fluid (CSF) samples obtained from a patient with RM using flow cytometry. Case presentation A 36-year-old woman with RA and generalized myasthenia gravis (MG) developed RM during a remission phase. Although both RA and MG were stable and well controlled, she noticed fever, headache, and transient sensory disturbance. Blood and CSF examination findings suggested aseptic meningitis, while brain magnetic resonance imaging revealed restricted portions of meningitis and associated cortical lesions, compatible with a diagnosis of RM. The dose of oral prednisolone was increased, which ameliorated the symptoms within 1 week along with improvement in CSF findings. This patient exhibited features of RM that were manifested in a manner independent of the activity of RA. An investigation of cellular immunity using CSF specimens with flow cytometry showed differences in regard to the pathogenesis of inflammation in the CSF as compared to outside of the central nervous system. In contrast to results obtained with paired blood samples, CSF cells at the peak stage of RM showed a marked increase in CCR3+ Th2 cells and marked decrease in CD8+ cells, suggesting an immunoregulatory disturbance in the CSF. Those findings indicated a CSF-specific activation of humoral immunity, resulting in augmentation of meningeal inflammation, as shown by excess synthesis of intrathecal IgG and markedly elevated interleukin-6 level. Results of the present detailed investigation of lymphocyte subsets revealed a discrepancy regarding the process of inflammation in this RM patient between CSF and blood samples. Conclusions RM is not a simple reflection of the immune status of RA, as the pathogenesis seems related to, at least in part, CSF-specific immunological dysregulation.
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Affiliation(s)
- Miki Oono
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Yoshimasa Fujita
- Department of Hematology and Immunology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Nobuaki Uchida
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Ukichiro Kawai
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Michiyo Fujita-Nakata
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Megumi Nakanishi
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Mitsuru Sanada
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Shigemi Nagayama
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan
| | - Makoto Matsui
- Department of Neurology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku-gun, Ishikawa, 920-0293, Japan.
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14
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Matsuda S, Yoshida S, Takeuchi T, Fujiki Y, Yoshikawa A, Makino S. Asymptomatic rheumatoid meningitis revealed by magnetic resonance imaging, followed by systemic rheumatic vasculitis: A case report and a review of the literature. Mod Rheumatol 2016; 29:370-376. [DOI: 10.1080/14397595.2016.1232333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Shogo Matsuda
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki City, Osaka, Japan
| | - Shuzo Yoshida
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki City, Osaka, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki City, Osaka, Japan
| | - Yohei Fujiki
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki City, Osaka, Japan
| | - Ayaka Yoshikawa
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki City, Osaka, Japan
| | - Shigeki Makino
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki City, Osaka, Japan
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15
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Yamashita K, Terasaki Y, Sakaguchi M, Nakatsuji Y, Yoshizaki K, Mochizuki H. [A case of rheumatoid meningitis presented with generalized seizure in whom MRI images were helpful for the diagnosis]. Rinsho Shinkeigaku 2015; 55:926-31. [PMID: 26511030 DOI: 10.5692/clinicalneurol.cn-000773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 65-years-old woman with rheumatoid meningitis presented with a generalized seizure. She has a 18-year history of rheumatoid arthritis, which has been successfully treated. She developed a generalized seizure. She was diagnosed as having subarachnoid hemorrhage, because the brain magnetic resonance imaging (MRI) showed increased fluid attenuated inversion recovery (FLAIR) signals in her left frontoparietal subarachnoid space. After one month of clinical stabilization, she developed numbness and weakness in her right lower extremity that spread to her right upper extremity and face. Brain MRI showed progression of subarachnoid lesion on FLAIR image and leptomeningeal enhancement on gadolinium-enhanced T1 weighted image. She was diagnosed as having rheumatoid meningitis, and methylprednisolone pulse therapy was started. Then, her symptoms and MRI findings were rapidly improved. Though rheumatoid meningitis is rare and presents a difficulty in the diagnosis, MRI features may support the diagnosis.
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Affiliation(s)
- Kazuya Yamashita
- Department of Neurology, Osaka University Graduate School of Medicine
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16
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Magaki S, Chang E, Hammond RR, Yang I, Mackenzie IRA, Chou BT, Choi SI, Jen JC, Pope WB, Bell DA, Vinters HV. Two cases of rheumatoid meningitis. Neuropathology 2015; 36:93-102. [DOI: 10.1111/neup.12238] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Shino Magaki
- Section of Neuropathology, Department of Pathology and Laboratory Medicine
| | | | | | | | - Ian R. A. Mackenzie
- Department of Pathology; University of British Columbia and Vancouver General Hospital; Vancouver British Columbia Canada
| | | | - Soo I. Choi
- Division of Rheumatology, Department of Medicine
| | | | | | - David A. Bell
- Department of Medicine; Western University; London Ontario Canada
| | - Harry V. Vinters
- Section of Neuropathology, Department of Pathology and Laboratory Medicine
- Department of Neurology
- Brain Research Institute; University of California, Los Angeles (UCLA) Medical Center and David Geffen School of Medicine; Los Angeles California USA
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Affiliation(s)
- Hiroki Yamaguchi
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Japan
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18
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Ito A, Sasaki R, Asahi M, Tomimoto H. [Diffusion-weighted MR imaging of meningeal involvement in Wegener's granulomatosis]. Rinsho Shinkeigaku 2014; 54:888-91. [PMID: 25420562 DOI: 10.5692/clinicalneurol.54.888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 65-year-old female with meningeal involvement in Wegener's granulomatosis (WG). At 52 years of age, she was diagnosed as having WG by lung biopsy and elevated proteinase3 anti-neutrophil cytoplasmic antibody titer. She had been maintained on prednisolone. Three weeks before admission, she developed deterioration of mental status. On examination, neurological abnormalities included right hemiparesis, confusion, memory loss, psychomotor slowing and agraphia. CSF was normal. Diffusion-weighted images (DWI) showed high intensity lesions in the subarachnoid space over the left hemisphere. Fluid attenuated inversion recovery (FLAIR) images showed high intensity signal in the subarachnoid space with mild swelling of the cortex and abnormal meningeal enhancement corresponding to the high intensity area on DWI. She was treated with intravenous administration of methylprednisolone (1,000 mg/day for 3 days) and cyclophosphamide, and gradually improved in symptoms and abnormal hyperintensity on DWI. Involvement of the meninges in WG is rare. The dura mater is involved more frequently than the pia mater. Pathological findings of the meninges in WG has been reported to be granulomatous inflammation. Restricted diffusion in the subarachnoid space has been described to occur in a viscous mixture of proteins and inflammatory cells, similarly to the DWI hyperintensity in pyogenic abscesses. In our case, abnormal hyperintensity on DWI was interpreted as a dense inflammatory infiltrate in the leptomeninges. Therefore, DWI and FLAIR image have been shown to be useful for demonstration of leptomeningeal lesions in WG.
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Affiliation(s)
- Ai Ito
- Department of Neurology, Mie University Graduate School of Medicine
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Roques M, Tanchoux F, Calvière L, Cuinat L, Lubrano V, Uro-Coste E, Cognard C, Larrue V, Bonneville F. MRI with DWI helps in depicting rheumatoid meningitis. J Neuroradiol 2014; 41:275-7. [DOI: 10.1016/j.neurad.2013.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 10/25/2022]
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Chronic repetitive nonprogressive epilepsia partialis continua due to rheumatoid meningitis. Seizure 2013; 22:80-2. [DOI: 10.1016/j.seizure.2012.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 10/11/2012] [Accepted: 10/13/2012] [Indexed: 11/22/2022] Open
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Bonnin N, Chiambaretta F, Ulla M, Taithe F, Chabert E, Claise B, Bacin F. Toxoplasmic pachymeningitis with visual field impairment in a single-eyed patient and a literature review. Oman J Ophthalmol 2012; 5:46-50. [PMID: 22557877 PMCID: PMC3339675 DOI: 10.4103/0974-620x.94768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
To describe the clinical features of a patient with toxoplasmic pachymeningitis and provide a review of the recent cases of pachymeningitis in the literature.Retrospective, observational case report. A one-eyed patient who presented to our institution with blurred vision, floaters, and visual field shrinkage. Review of clinical, laboratory, perimetric, and radiologic records of the patient and description of the efficacy of antibiotic therapy. The signs of ocular impairment, including visual acuity, visual field, and magnetic resonance imaging (MRI) changes. A one-eyed patient who complained of blurred vision and unexplained visual field shrinkage was evaluated. The diagnosis of toxoplasmic pachymeningitis was confirmed by existence of a toxoplasmic seroconversion, cerebrospinal fluid abnormalities, radiological features, absence of other diagnoses, improvement of symptoms, and resolution of pachymeningitis in MRI with oral trimethoprim-sulfamethoxazole combination.Pachymeningitis is a rare disease and toxoplasmic pachymeningitis has never been described. Among the various infectious causes, screening for toxoplasmosis must be performed because it can lead to pachymeningitis and sequelae. Variable features may lead to misdiagnosis and delay in the treatment of this sight-threatening and potentially fatal disease.
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Affiliation(s)
- Nicolas Bonnin
- CHU Clermont-Ferrand, Pôle Médecine Interne-Ophtalmologie-ORL, Service d'Ophtalmologie, Clermont-Ferrand, France
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Gomez C, Wu J, Pope W, Vinters H, Desalles A, Selch M. Pineocytoma with diffuse dissemination to the leptomeninges. Rare Tumors 2011; 3:e53. [PMID: 22355508 PMCID: PMC3282458 DOI: 10.4081/rt.2011.e53] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 10/05/2011] [Accepted: 11/02/2011] [Indexed: 11/23/2022] Open
Abstract
Pineal parenchymal tumors are rare. Of the three types of pineal parenchymal tumors, pineocytomas are the least aggressive and are not known to diffusely disseminate. In this paper, we report the successful treatment of a case of pineocytoma with diffuse leptomeningeal relapse following initial stereotactic radiotherapy. A 39-year-old female presented with headaches, balance impairment, urinary incontinence, and blunted affect. A pineal mass was discovered on magnetic resonance imaging (MRI). A diagnosis of pineocytoma was established with an endoscopic pineal gland biopsy, and the patient received stereotactic radiotherapy. Ten years later, she developed diffuse leptomeningeal dissemination. The patient was then successfully treated with craniospinal radiation therapy. Leptomeningeal spread may develop as late as 10 years after initial presentation of pineocytoma. Our case demonstrates the importance of long-term follow-up of patients with pineal parenchymal tumors following radiation therapy, and the efficacy of craniospinal radiation in the treatment of leptomeningeal dissemination.
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