1
|
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.
Collapse
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
| |
Collapse
|
2
|
Mitrović J, Hrkač S, Tečer J, Golob M, Ljilja Posavec A, Kolar Mitrović H, Grgurević L. Pathogenesis of Extraarticular Manifestations in Rheumatoid Arthritis-A Comprehensive Review. Biomedicines 2023; 11:biomedicines11051262. [PMID: 37238933 DOI: 10.3390/biomedicines11051262] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023] Open
Abstract
Rheumatoid arthritis (RA) is among the most prevalent and debilitating autoimmune inflammatory chronic diseases. Although it is primarily characterized by destructive peripheral arthritis, it is a systemic disease, and RA-related extraarticular manifestations (EAMs) can affect almost every organ, exhibit a multitude of clinical presentations, and can even be asymptomatic. Importantly, EAMs largely contribute to the quality of life and mortality of RA patients, particularly substantially increased risk of cardiovascular disease (CVD) which is the leading cause of death in RA patients. In spite of known risk factors related to EAM development, a more in-depth understanding of its pathophysiology is lacking. Improved knowledge of EAMs and their comparison to the pathogenesis of arthritis in RA could lead to a better understanding of RA inflammation overall and its initial phases. Taking into account that RA is a disorder that has many faces and that each person experiences it and responds to treatments differently, gaining a better understanding of the connections between the joint and extra-joint manifestations could help to create new treatments and improve the overall approach to the patient.
Collapse
Affiliation(s)
- Joško Mitrović
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Internal Medicine, Dubrava University Hospital, School of Medicine and Faculty of Pharmacy and Biochemistry, University of Zagreb, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia
| | - Stela Hrkač
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Internal Medicine, Dubrava University Hospital, School of Medicine and Faculty of Pharmacy and Biochemistry, University of Zagreb, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia
| | - Josip Tečer
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Internal Medicine, Dubrava University Hospital, School of Medicine and Faculty of Pharmacy and Biochemistry, University of Zagreb, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia
| | - Majda Golob
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Internal Medicine, Dubrava University Hospital, School of Medicine and Faculty of Pharmacy and Biochemistry, University of Zagreb, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia
| | - Anja Ljilja Posavec
- Polyclinic for the Respiratory Tract Diseases, Prilaz Baruna Filipovića 11, 10000 Zagreb, Croatia
| | - Helena Kolar Mitrović
- Department of Rheumatology and Rehabilitation, Zagreb University Hospital Center, University of Zagreb School of Medicine, Kišpatićeva 12, 10000 Zagreb, Croatia
| | - Lovorka Grgurević
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Anatomy, "Drago Perovic", School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| |
Collapse
|
3
|
Ide T, Kawanami T, Tada Y, Eriguchi M. Overlapping rheumatoid meningitis with anti-N-methyl-D-aspartate receptor encephalitis: A case report. Clin Case Rep 2023; 11:e7199. [PMID: 37155424 PMCID: PMC10122683 DOI: 10.1002/ccr3.7199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 05/10/2023] Open
Abstract
A 66-year-old woman in treatment for rheumatoid meningitis was found to be positive for anti-N-methyl-D-aspartate receptor (NMDAR) antibodies in the cerebrospinal fluid, and intravenous immunoglobulin improved her psychiatric symptoms. The co-existence of NMDAR antibodies should be considered in cases of poor response to treatments or atypical symptoms in rheumatoid meningitis.
Collapse
Affiliation(s)
- Toshihiro Ide
- Department of Internal Medicine, Division of NeurologySaga University, Faculty of MedicineSagaJapan
| | - Takeru Kawanami
- Department of Internal Medicine, Division of NeurologySaga University, Faculty of MedicineSagaJapan
| | - Yoshifumi Tada
- Department of Internal Medicine, Division of RheumatologySaga University, Faculty of MedicineSagaJapan
| | - Makoto Eriguchi
- Department of Internal Medicine, Division of NeurologySaga University, Faculty of MedicineSagaJapan
| |
Collapse
|
4
|
Atalar E, Yurdakul FG, Gök K, Güler T, Erten Ş, Yaşar E, Bodur H. Motor neuron disease in a patient with overlap syndrome (rheumatoid arthritis; systemic lupus erythematosus, Sjogren's syndrome). Rheumatol Int 2023; 43:367-372. [PMID: 36117188 PMCID: PMC9483514 DOI: 10.1007/s00296-022-05207-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/06/2022] [Indexed: 02/07/2023]
Abstract
Autoimmune rheumatic diseases have their own specific clinical presentation, and can affect multiple systems. Neurological involvement of autoimmune rheumatic diseases may involve both the central and peripheral nervous systems. Inflammation of neural tissue, autoantibody-mediated reactions, and small vessel vasculitis may be effective in the pathogenesis of neuropathy in autoimmune rheumatological diseases. Autoimmune rheumatic disease with pure motor neuron involvement is very rare in the literature. The case is here presented of a 58-year-old female patient who presented with the complaints of increasing pain and weakness in the extremities and was diagnosed with lower motor neuron disease and overlap syndrome. The patient was treated with cyclophosphamide, pulse steroid, hydroxychloroquine and intravenous immunoglobulin. After 3 months of treatment, a significant improvement was observed in the patient's clinical complaints and laboratory parameters. In conclusion, some patients with undiagnosed autoimmune rheumatic diseases may have neurological complaints. Clinicians should investigate patients with such neurological complaints for autoimmune rheumatic diseases.
Collapse
Affiliation(s)
- Ebru Atalar
- Department of Rheumatology, Ankara City Hospital, Bilkent Blv. No:1, Çankaya, 06800, Ankara, Turkey.
| | - Fatma Gül Yurdakul
- Department of Physical Therapy and Rehabilitation, Ankara City Hospital, Ankara, Turkey
| | - Kevser Gök
- Department of Rheumatology, Ankara City Hospital, Bilkent Blv. No:1, Çankaya, 06800, Ankara, Turkey
| | - Tuba Güler
- Department of Physical Therapy and Rehabilitation, Ankara City Hospital, Ankara, Turkey
| | - Şükran Erten
- Department of Rheumatology, Ankara City Hospital, Bilkent Blv. No:1, Çankaya, 06800, Ankara, Turkey
| | - Evren Yaşar
- Department of Physical Therapy and Rehabilitation, Ankara City Hospital, Ankara, Turkey
| | - Hatice Bodur
- Department of Physical Therapy and Rehabilitation, Ankara City Hospital, Ankara, Turkey
| |
Collapse
|
5
|
Nishiwaki T, Ikedo T, Hashimura N, Tanaka K, Ikeda Y, Hatakeyama K, Ohta-Ogo K, Kushi Y, Shimonaga K, Hamano E, Ohta T, Imamura H, Mori H, Iihara K, Kataoka H. A case of rheumatoid meningitis with symptomatic middle cerebral artery stenosis. J Neuropathol Exp Neurol 2023; 82:180-182. [PMID: 36326580 DOI: 10.1093/jnen/nlac099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Takayuki Nishiwaki
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Taichi Ikedo
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoki Hashimura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Ikeda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Keiko Ohta-Ogo
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuji Kushi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Shimonaga
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Eika Hamano
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hisae Mori
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| |
Collapse
|
6
|
Nakajima H, Tsuchiya T, Shimizu S, Murata T, Suzuki H. Angiomatous meningioma associated with rapidly aggravated peritumoral leptomeningitis: A case report. Surg Neurol Int 2023; 14:159. [PMID: 37151464 PMCID: PMC10159325 DOI: 10.25259/sni_54_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/20/2023] [Indexed: 05/09/2023] Open
Abstract
Background A special type of meningioma is known to have infiltrated inflammatory cells within the tumor, associated with peritumoral inflammation. However, there have been no reports of meningioma with inflammatory response only around the tumor, without inflammatory cells within the tumor itself. Case Description A 70-year-old woman presented with transient right hemiparesis due to an extra-axial tumor on the left frontal convexity. The tumor appeared hypointense on T1-weighted magnetic resonance images and hyperintense on T2-weighted images without peritumoral edema, and was homogenously enhanced associated with the peritumoral leptomeningeal enhancement. Cerebrospinal fluid examination showed an increase in the number of inflammatory cells with a predominance of mononuclear cells. During the following 1 month, the tumor size was unchanged, but the peritumoral leptomeningeal enhancement was remarkably enlarged with uncontrolled focal seizures. The tumor was subtotally removed and semisolid substances in the subarachnoid space were biopsied. Pathological examination with immunostaining revealed angiomatous meningioma: the tumor had no inflammatory cell infiltration within it, but was associated with the infiltration of immunoglobulin G4-negative lymphocytes into the border zone between the tumor and the dura mater, as well as numerous neutrophils and fibrinous exudates in the peritumoral subarachnoid space. The tumor removal rapidly improved the leptomeningeal enhancement and inflammatory reactions. Conclusion The authors reported the first case of angiomatous meningioma associated with massive peritumoral inflammation without inflammatory infiltrates within the tumor itself.
Collapse
Affiliation(s)
- Hideki Nakajima
- Department of Neurosurgery, Suzuka General Hospital, Suzuka, Japan
- Corresponding author: Hideki Nakajima, Department of Neurosurgery, Suzuka General Hospital, Suzuka, Japan.
| | - Takuro Tsuchiya
- Department of Neurosurgery, Suzuka General Hospital, Suzuka, Japan
| | | | - Tetsuya Murata
- Department of Pathology, Suzuka General Hospital, Suzuka, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Rubeli S, Conen A, Diepers M, Bernasconi L, Hasler P, Mueller RB. Successful Treatment of Rheumatoid Meningitis Associated With a Decrease of ACPA Antibody Index. J Clin Rheumatol 2022; 28:e667-e669. [PMID: 35041360 DOI: 10.1097/rhu.0000000000001718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
Junjun Q, Mingdong L. Exploring the Anti-Rheumatoid Arthritis Mechanisms of Curcumin. J BIOMATER TISS ENG 2021. [DOI: 10.1166/jbt.2021.2756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: To research curcumin on rheumatoid arthritis (RA) symptoms. Materials and Methods: Dividing Sixty SD male rats among six groups: normal control group, model group, dexamethasone (DXM) group and curcumin low, medium and high dosage groups (25, 50, 100 mg/kg body
weight) every days. We adopted the CIA (collagen induced arthritis) rat model. All rats were subjected to 28 days of intragastric administration wherein we observed the rats’ state, weight, degree of paw swelling, arthritis index and pathological changes of ankle joints. Their serologic
contents of IL-1β, IL-6 and TNF-α were examined by Elisa method and IKK-α, IKK-β and NF-κB in joint synovial tissues were tested via IHC assay. Results: Curcumin inhibited paw swelling within the CIA rat model, decreasing
the serologic content of IL-1β, IL-6 and TNF-α. It also decreased the protein expressions of IKK-α, IKK-β and and NF-κB in synovial tissues. Its effects were dose-dependent and weaker than those of DXM. Conclusion: Curcumin
is effective against RA by means of transcribing the IKK-α/-β/NF-κB pathway
Collapse
Affiliation(s)
- Qin Junjun
- Department of Orthopaedics, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhang Autonomous Region, 530021, China
| | - Li Mingdong
- Department of Orthopaedics and Traumatology, Hainan General Hospital, Haikou, Hainan, 570311, China
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Shadmani G, Simkins TJ, Assadsangabi R, Apperson M, Hacein-Bey L, Raslan O, Ivanovic V. Autoimmune diseases of the brain, imaging and clinical review. Neuroradiol J 2021; 35:152-169. [PMID: 34490814 DOI: 10.1177/19714009211042879] [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] [Indexed: 11/16/2022] Open
Abstract
There is an extensive spectrum of autoimmune entities that can involve the central nervous system, which has expanded with the emergence of new imaging modalities and several clinicopathologic entities. Clinical presentation is usually non-specific, and imaging has a critical role in the workup of these diseases. Immune-mediated diseases of the brain are not common in daily practice for radiologists and, except for a few of them such as multiple sclerosis, there is a vague understanding about differentiating them from each other based on the radiological findings. In this review, we aim to provide a practical diagnostic approach based on the unique radiological findings for each disease. We hope our diagnostic approach will help radiologists expand their basic understanding of the discussed disease entities and narrow the differential diagnosis in specific clinical scenarios. An understanding of unique imaging features of these disorders, along with laboratory evaluation, may enable clinicians to decrease the need for tissue biopsy.
Collapse
Affiliation(s)
- Ghazal Shadmani
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Tyrell J Simkins
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Michelle Apperson
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Osama Raslan
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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: 5] [Impact Index Per Article: 1.3] [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.
Collapse
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
| |
Collapse
|
14
|
Yamaoka M, Izumi T, Eura N, Sasaki R, Kiriyama T, Sugie K. [Elevation of cerebrospinal fluid anti-cyclic citrullinated peptides antibody index is useful for rheumatoid meningitis preceding neurological symptoms without arthritis: a case report]. Rinsho Shinkeigaku 2020; 60:631-635. [PMID: 32779602 DOI: 10.5692/clinicalneurol.cn-001458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
We report a 62-year-old female with rheumatoid meningitis. She presented with mental disorder, loss of consciousness, generalized seizures, and cognitive impairment. Brain MRI demonstrated high intensity lesions and abnormal enhancement along the left frontal and parietal sulci. Her serum and cerebrospinal fluid were positive for anti-cyclic citrullinated peptides (CCP) antibody, and the antibody index of cerebrospinal fluid anti-CCP antibody increased, which led us to suspect rheumatoid meningitis. Her symptoms improved immediately by methylpredonisolone pulse therapy and anti-CCP antibody turned negative in cerebrospinal fluid. However, she revealed arthritis with the reduction of betamethasone and was diagnosed as rheumatoid arthritis. We suggest that the elevation of antibody index of cerebrospinal fluid anti-CCP antibody is useful in the diagnosis of rheumatoid meningitis preceding neurological symptoms without arthritis, and anti-CCP antibody in cerebrospinal fluid may be helpful as the evaluation of the treatment.
Collapse
Affiliation(s)
| | | | | | | | | | - Kazuma Sugie
- Department of Neurology, Nara Medical University
| |
Collapse
|
15
|
Higashida-Konishi M, Izumi K, Tsukamoto M, Ohya H, Takasugi N, Hama S, Hayashi Y, Ushikubo M, Akiya K, Kazuhiro A, Okano Y, Oshima H. Anti-cyclic citrullinated peptide antibody in the cerebrospinal fluid in patients with rheumatoid arthritis who have central nervous system involvement. Clin Rheumatol 2020; 39:2441-2448. [PMID: 32356228 DOI: 10.1007/s10067-020-05044-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/08/2020] [Accepted: 03/10/2020] [Indexed: 11/26/2022]
Abstract
Central nervous system (CNS) involvement, including encephalopathy, encephalitis, leptomeningitis, and pachymeningitis, in rheumatoid arthritis (RA) is rather rare. We report the case of a 61-year-old female with a history of RA in remission for 7 years, who presented with numbness, weakness of the left upper limb, dysarthria, and headache. Magnetic resonance imaging (MRI) of the brain showed meningeal enhancement in the frontal, parietal, and temporal lobes. Cerebrospinal fluid (CSF) examination detected high levels of both rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA), with a high ACPA-immunoglobulin G index (> 2.0). She was diagnosed with rheumatoid meningitis. Following combined therapy with oral prednisolone and intravenous infusion of cyclophosphamide, her symptoms promptly improved. After treatment, RF and ACPA levels in the CSF were reduced, and MRI showed improvement of the meningeal structures. This case, along with existing literature, suggests that the ACPA level in the CSF may serve as a useful marker for diagnosing of CNS involvement in RA, as well as an index of effectiveness of the associated treatment.
Collapse
Affiliation(s)
- Misako Higashida-Konishi
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Keisuke Izumi
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan.
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Masako Tsukamoto
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Hiroaki Ohya
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Nozomi Takasugi
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Satoshi Hama
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Yutaro Hayashi
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Mari Ushikubo
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Kumiko Akiya
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Araki Kazuhiro
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Yutaka Okano
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| | - Hisaji Oshima
- National Hospital Organization Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo, 152-8902, Japan
| |
Collapse
|
16
|
Trabelsi M, Romand X, Gilson M, Vaillant M, Guerne PA, Hayem G, Bertolini E, Baillet A, Gaudin P. Rheumatoid Meningitis a Rare Extra-Articular Manifestation of Rheumatoid Arthritis: Report of 6 Cases and Literature Review. J Clin Med 2020; 9:jcm9061625. [PMID: 32471260 PMCID: PMC7356493 DOI: 10.3390/jcm9061625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives. Central neurological manifestations of rheumatoid arthritis (RA) like rheumatoid meningitis (RM) are rare, little known and have a high rate of morbi-mortality. METHODS. We described six cases of RM that were directly related to RA activity after exhaustive assessment. RESULTS. They were mainly women, aged of 50 to 69. All were positive for anti-cyclic citrullinated peptide antibodies and half for rheumatoid factors. RA activity, duration, and treatments were heterogeneous including oral steroids, conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) and biologic DMARDs. Symptoms were various, with acute or progressive beginning; main were: generalized or focal seizure (4/6), fever (3/6), headaches (3/6), and frontal syndrome (2/6). Imaging lesions were four leptomeningitis, one pachymeningitis, and one association of both. MRI usually showed hypersignal in various territories in T2-FLAIR (fluid attenuated inversion recovery) mode, and enhancement in T1-weighted mode after gadolinium injection. All patients had lumbar puncture that found sterile cerebrospinal fluid, no neoplasic cell, elevated cell count in 5/6 cases and elevated proteins concentration in 3/6 cases. Cerebral biopsy was possible for three patients, and definitively confirmed the diagnosis of aseptic lepto- or pachymenintis, excluding vasculitis and lymphoma. Different treatments were used like intravenous high dose steroids, immunoglobulins or biologic DMARDs, with variable clinical and imaging outcome: one death, one complete recovery, and four recoveries with sequelae. Conclusions. Clinical symptoms, imaging, lumbar puncture, and serological studies are often nonspecific, only histologic examination can confirm the diagnosis of RM. Any central neurological manifestation in RA patients, even in quiescent and ancient RA, should warn the physician.
Collapse
Affiliation(s)
- Mélanie Trabelsi
- Rheumatology Department, CHU Grenoble Alpes, Hôpital Sud, 38130 Echirolles, France; (X.R.); (M.G.); (A.B.); (P.G.)
- Correspondence:
| | - Xavier Romand
- Rheumatology Department, CHU Grenoble Alpes, Hôpital Sud, 38130 Echirolles, France; (X.R.); (M.G.); (A.B.); (P.G.)
- GREPI TIMC, CNRS UMR 5525, Université Grenoble Alpes, 38000 Grenoble, France
| | - Mélanie Gilson
- Rheumatology Department, CHU Grenoble Alpes, Hôpital Sud, 38130 Echirolles, France; (X.R.); (M.G.); (A.B.); (P.G.)
| | - Mathieu Vaillant
- Neurology Department, CHU Grenoble Alpes, Hôpital Nord, 38000 Grenoble, France;
| | | | - Gilles Hayem
- Rheumatology Department, Groupe Hospitalier Paris Saint Joseph, 75014 Paris, France;
| | - Ewa Bertolini
- Rheumatology Department, CH Annecy, 74370 Annecy, France;
| | - Athan Baillet
- Rheumatology Department, CHU Grenoble Alpes, Hôpital Sud, 38130 Echirolles, France; (X.R.); (M.G.); (A.B.); (P.G.)
- GREPI TIMC, CNRS UMR 5525, Université Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Gaudin
- Rheumatology Department, CHU Grenoble Alpes, Hôpital Sud, 38130 Echirolles, France; (X.R.); (M.G.); (A.B.); (P.G.)
- GREPI TIMC, CNRS UMR 5525, Université Grenoble Alpes, 38000 Grenoble, France
| |
Collapse
|
17
|
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.
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Qin Z, Kim J, Valencia D, Hamoodi L, Neltner J, Sizemore T, Lightfoot R. Rheumatoid meningitis: A case report and review of the literature. Neurol Clin Pract 2020; 10:73-83. [PMID: 32190423 PMCID: PMC7057072 DOI: 10.1212/cpj.0000000000000678] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 03/08/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Rheumatoid arthritis is a systemic inflammatory disorder, which can involve many organs; among which, CNS involvement, as in rheumatoid meningitis (RM), is rare and difficult to recognize. Our goal is to present collective data of RM cases to better characterize this disease process and to start new discussions about pathophysiology, diagnosis, and treatment. RECENT FINDINGS Since Kato et al., 39 cases of RM have been reported. Approximately 59% were women, presenting with neurologic deficits (56%) and diagnosed by MRI findings, leptomeningeal enhancement (69%), after CSF analysis. Seventy-four percent were treated with corticosteroids, 64% as maintenance therapy, with 46% experiencing improvement or resolution in symptoms without relapse. SUMMARY Diagnosis and prognosis of RM has drastically changed since the year 2000. Early detection with CSF and MRI or biopsy findings, coupled with early treatment using corticosteroids and immunologic therapy, has reduced mortality in this population.
Collapse
|
20
|
Yagita K, Shinde A, Suenaga T. Rheumatoid meningitis can present MRI findings that mimic chronic subdural haematoma. BMJ Case Rep 2019; 12:12/8/e229642. [PMID: 31444262 DOI: 10.1136/bcr-2019-229642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 65-year-old woman with long-standing rheumatoid arthritis (RA) experienced a recurrent tingling sensation in her left arm followed by aphasia and a tingling sensation in her right arm. A subsequent imaging study showed bilateral subdural fluid accumulation and we initially diagnosed her with a transient ischaemic attack and chronic subdural haematoma (CSDH). The cerebral spinal fluid study revealed an inflammatory response without any indications of infection or malignant tumours. After a meningeal biopsy, we redefined the diagnosis to rheumatoid meningitis (RM), and the patient showed remarkable improvement with prednisolone administration. RM should be considered as an alternative diagnosis when examining central nervous system diseases in patients with RA, as RM presents a highly variable clinical picture with image findings similar to those of CSDH.
Collapse
Affiliation(s)
- Kaoru Yagita
- Department of Neurology, Tenri Hospital, Tenri, Nara, Japan
| | - Akiyo Shinde
- Department of Neurology, Tenri Hospital, Tenri, Nara, Japan
| | | |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Scheitel M, Ives ST, Nasr R, Nolan MW. When the plot thickens: a rare complication of rheumatoid arthritis. J Community Hosp Intern Med Perspect 2019; 9:143-146. [PMID: 31044046 PMCID: PMC6484464 DOI: 10.1080/20009666.2019.1593780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/07/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction: Rheumatoid arthritis (RA) is a common illness with many extraarticular manifestations. Rheumatoid pachymeningitis is a rare neurologic complication of this common disease. Here in we present a patient with longstanding RA who developed this uncommon complication. Case description: A 75-year-old woman with longstanding RA presented to the clinic with multiple seizure-like spells per day. Upon admission to the hospital, brain MRI showed enhancement of the meninges. After an extensive workup for possible other infectious or inflammatory causes, the patient was diagnosed with rheumatoid pachymeningitis. Conclusion: Rheumatoid pachymeningitis is a rare complication of RA that usually occurs late in the disease course. It may have many neurologic manifestations include mimicking seizure or stroke and must be considered in patients with RA presenting with neurologic symptoms. Pachymeningitis is treated distinctly from articular RA, so early recognition can lead to appropriate treatment.
Collapse
Affiliation(s)
- Marianne Scheitel
- Department of Internal Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Samuel T Ives
- Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.,Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Rawad Nasr
- Medicine, University of Minnesota, Minneapolis, MN, USA.,Division of Rheumatology, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Marc W Nolan
- Division of Rheumatology, HealthPartners, Saint Paul, MN, USA
| |
Collapse
|
23
|
Grose D, Linger M, Tinni S, Sahathevan R. Rheumatoid meningitis: a rare cause of unilateral pachymeningitis. BMJ Case Rep 2019; 12:12/4/e227905. [PMID: 30948395 DOI: 10.1136/bcr-2018-227905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An 87-year-old woman with quiescent rheumatoid arthritis, not on immunosuppressive therapy, presented with unilateral arm weakness, confusion and visual hallucinations. There were no infective symptoms or history of malignancy. Cerebrospinal fluid (CSF) analysis demonstrated lymphocytosis and raised protein, without flow cytometric or cytological abnormalities. Viral, bacterial, mycobacterial and fungal testing of CSF and serum were negative. MRI brain indicated unilateral leptomeningeal enhancement. There was no evidence of occult malignancy on CT imaging of the chest, abdomen and pelvis. Rheumatoid factor and anticyclic citrullinated peptide were strongly positive. The patient declined meningeal biopsy but responded to treatment with corticosteroid therapy.
Collapse
Affiliation(s)
- Daniel Grose
- Internal Medicine Services, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Matthew Linger
- Internal Medicine Services, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Samara Tinni
- Internal Medicine Services, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Ramesh Sahathevan
- Internal Medicine Services, Ballarat Health Services, Ballarat, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| |
Collapse
|
24
|
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]
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Gherghel N, Stan A, Stan H. Pearls & Oy-sters: Rheumatoid meningitis occurring during treatment with etanercept. Neurology 2018; 91:806-808. [DOI: 10.1212/wnl.0000000000006397] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
28
|
Akamatsu M, Maki F, Akiyama H, Hara D, Hoshino M, Hasegawa Y. Rheumatoid meningitis presenting with a stroke-like attack treated with recombinant tissue plasminogen activator: a case presentation. BMC Neurol 2018; 18:139. [PMID: 30189853 PMCID: PMC6126002 DOI: 10.1186/s12883-018-1143-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 08/29/2018] [Indexed: 11/20/2022] Open
Abstract
Background Rheumatoid meningitis presenting with a stroke-like attack (RMSA) is a rare manifestation of rheumatoid arthritis (RA). When the patients arrive within the time-window for recombinant tissue plasminogen activator (rt-PA) infusion therapy, no diagnostic protocol has been established. Case presentation A 55-year-old woman was brought by ambulance to our hospital with complaints of sudden-onset dysarthria and left arm numbness. The National Institutes of Health Stroke Scale (NIHSS) score was 5, and the Alberta Stroke Program Early CT Score was 8. She was diagnosed with acute embolic stroke. At 4 h, 6 min after onset, intravenous administration of rt-PA (alteplase, 0.6 mg/kg) was started. Her neurological deficits improved rapidly, and her NIHSS score was 1. Brain MRI was then performed. There was no hemorrhagic transformation, but the MRI findings were not compatible with ischemic stroke. She had a past history of RA diagnosed 6 months earlier, and she had been treated with methotrexate (10 mg daily). She was diagnosed with RMSA, and continuous infusion of methylprednisolone 1000 mg daily was started for 3 days. The high signal intensity on the FLAIR image disappeared. Conclusion CT-based decision-making for rt-PA injection is reasonable, but MRI is needed for the early diagnosis of RMSA. In this case, it is particularly important that neither adverse events nor bleeding complications were observed, suggesting the safety of CT-based thrombolytic therapy in RMSA.
Collapse
Affiliation(s)
- Masashi Akamatsu
- Department of Neurology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Futaba Maki
- Department of Neurology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan.
| | - Hisanao Akiyama
- Department of Neurology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Daisuke Hara
- Department of Neurology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Masashi Hoshino
- Department of Neurology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| |
Collapse
|
29
|
Schuster S, Braass H, Iking-Konert C, Schnoor U, Matschke J, Gerloff C, Thomalla G, Magnus T. Rheumatoid meningitis: A rare cause of aseptic meningitis with frequently stroke-like episodes. Neurol Clin Pract 2018; 8:451-455. [PMID: 30564500 DOI: 10.1212/cpj.0000000000000504] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/08/2018] [Indexed: 11/15/2022]
Abstract
Background Rheumatoid meningitis (RM) is a rare manifestation of rheumatoid arthritis (RA) and may present with stroke-like episodes. We describe diagnostic findings and the outcome in patients with RM. Methods We identified 6 patients with RM in different stages of RA mostly admitted with stroke-like episodes or common features of meningitis. We used MRI, CSF, and histology for in-depth characterization. Results We observed RM in 2 patients without history of RA, 1 patient with early seropositive RA, and 3 patients with late-stage RA. Recurrent stroke-like episodes occurred in 5 of 6 patients; headache and partial status epilepticus was in the foreground in 1 patient. Symptoms were accompanied by constitutional symptoms in all patients. MRI showed leptomeningeal or pachymeningeal fluid-attenuated inversion recovery hyperintensities with contrast enhancement. CSF mostly showed mild pleocytosis but can initially be normal. Anticitrullinated peptide antibodies (ACPA) and rheumatoid factor (RF) were positive in all patients. Histopathology revealed granulomatous inflammation in 2 patients. Response to steroids was prompt and further immunosuppressive treatment prevented recurrence. Conclusions RM is a rare manifestation of RA and often presents with stroke-like episodes. It is currently not implemented in the workup of aseptic meningitis in national guidelines. Crucial clues for diagnosis included recurrent stroke-like episodes refractory to antiepileptic treatment, headache and constitutional symptoms, meningeal enhancement on MRI, CSF pleocytosis, and positive serology findings for ACPA and RF. Prognosis is favorable with early immunosuppressive treatment.
Collapse
Affiliation(s)
- Simon Schuster
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| | - Hanna Braass
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| | - Christof Iking-Konert
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| | - Ulrike Schnoor
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| | - Jakob Matschke
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| | - Christian Gerloff
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| | - Götz Thomalla
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| | - Tim Magnus
- Department of Neurology (SS, HB, CG, GT, TM), Center for Internal Medicine (US), and Institute of Neuropathology (JM), University Hospital Hamburg-Eppendorf; and Klinik für Rheumatologie und Immunologie (CI-K), Klinikum Bad Bramstedt, Germany
| |
Collapse
|
30
|
Lubomski M, Sy J, Buckland M, Lee AS, Richards B, Thompson E, Fulham M, Breen N, Morris K, Halmagyi GM. Rheumatoid leptomeningitis presenting with an acute neuropsychiatric disorder. Pract Neurol 2018; 19:68-71. [PMID: 30097553 DOI: 10.1136/practneurol-2018-001978] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2018] [Indexed: 11/04/2022]
Abstract
Leptomeningitis is a rare central nervous system manifestation of rheumatoid arthritis, generally in patients with established chronic rheumatoid disease. We report a 41-year-old man without previous rheumatoid arthritis or psychiatric disorder who presented with an acute neuropsychiatric disturbance and polyarthralgia. His MR scan of brain showed asymmetric bifrontal leptomeningitis, confirmed on (18F)-fluoro-D-glucose-positron emission tomography. Other investigations showed highly positive serum and cerebrospinal fluid anti-cyclic citrullinated peptide. A leptomeningeal biopsy showed necrotising leptomeningeal inflammation with ill-defined granulomas and lymphoplasmacytic infiltrate without organisms. Prolonged high-dose corticosteroids and then rituximab resulted in recovery. Chronic leptomeningitis can present with an acute neuropsychiatric disorder. We highlight that early rheumatoid disease can, rarely, cause a chronic leptomeningitis, reversible with immunotherapy.
Collapse
Affiliation(s)
- Michal Lubomski
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Joanne Sy
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Discipline of Pathology, University of Sydney, Sydney, New South Wales, Australia
| | - Andie S Lee
- Department of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Bethan Richards
- Department of Rheumatology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Elizabeth Thompson
- Radiology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael Fulham
- Department of Molecular Imaging and Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Nora Breen
- Neuropsychology Unit, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Kirsty Morris
- Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - G Michael Halmagyi
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| |
Collapse
|
31
|
|
32
|
Dimberg EL. Rheumatology and Neurology. Continuum (Minneap Minn) 2017; 23:691-721. [DOI: 10.1212/con.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
33
|
Choi SJ, Ho Park Y, Kim JA, Han JH, Choe G, Kim S. Pearls & Oy-sters: Asymmetric meningeal involvement is a common feature of rheumatoid meningitis. Neurology 2017; 88:e108-e110. [DOI: 10.1212/wnl.0000000000003744] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
34
|
Abstract
Rheumatic disease represents a broad spectrum of systemic conditions manifested by multisystem involvement and mediated by autoimmunity and inflammation. Their neurological complications may occur at any point in the disease process and are diagnostically challenging. For years central nervous system (CNS) was considered as a system uniquely protected from effects of the immune system because of the blood-brain barrier. Indeed, under physiological conditions immune access to CNS is tightly regulated. Over the past decade, new scientific discoveries highlighted pathways by which immune and neurological systems interact, including a variety of mechanisms controlling permeability of blood-brain barrier, and specific roles that CD4+ and CD8+ T-lymphocytes play in initiation of specific adaptive immune response to neural specific antigens. This leads to release of proinflammatory cytokines (interleukin 1, interleukin 6, and tumor necrosis factor alpha). In addition, B-cells involved in CNS inflammation produce antibodies against membrane bound and soluble antigens. This article describes specific neurological manifestations of the most common autoimmune rheumatic disorders.
Collapse
Affiliation(s)
- Svetlana Lvovich
- From the Section of Rheumatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
| | - Donald P Goldsmith
- From the Section of Rheumatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
| |
Collapse
|
35
|
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
| |
Collapse
|