Pachymeningitis and optic neuritis in rheumatoid arthritis: MRI findings

Systemic Inflammation by Collagen-Induced Arthritis Affects the Progression of Age-Related Macular Degeneration Differently in Two Mouse Models of the Disease

Purpose

Age-related macular degeneration (AMD) shares similar risk factors and inflammatory responses with rheumatoid arthritis (RA). Previously, we identified increased risk for dry AMD among patients with RA compared to control subjects, using retrospective data analysis. In this current study, we investigate the role of systemic inflammation triggered in a murine model of arthritis on choroidal neovascularization and retinal pigment epithelium (RPE) degeneration mouse models.

Methods

Collagen-induced arthritis (CIA) was induced in C57BL/6J mice prior to laser-induced choroidal neovascularization (CNV; wet AMD model) or sodium iodate-induced retinal degeneration (NaIO3; dry AMD model). CNV lesion size and retinal thickness were quantified by optical coherence photography (OCT), visual function was analyzed using optokinetic response and electroretinography, RPE morphology was examined by immunohistochemistry, and inflammatory gene expression was analyzed by quantitative PCR.

Results

CIA mice demonstrated decreased spatial acuity and contrast sensitivity, whereas no difference was observed in the RPE-generated c-wave. CNV lesion size was decreased in CIA mice. NaIO3 decreased c-wave amplitude, as well as retinal thickness, which was augmented by CIA. NaIO3 treatment resulted in loss of normal RPE hexagonal shape, which was further aggravated by CIA. Increased Cxcl9 expression was observed in the presence of CIA and CIA combined with AMD. Disease severity differences were observed between sexes.

Conclusions

Our data suggest systemic inflammation by CIA results in increased pathology in a dry AMD model, whereas it reduces lesions in a wet AMD model. These findings highlight the need for additional investigation into the role of secondary inflammation and sex-based differences on AMD.

Optic Neuropathy with Headache and Palpable Temporal Arteries Due to Hypertrophic Pachymeningitis Rather than Giant Cell Arteritis

Purpose: To report a case of optic neuropathy diagnosed by color Doppler ultrasonography and Gadolinium-enhanced cerebral magnetic resonance imaging (MRI).Case report: A 79-year-old woman presented with headache and vision loss in her left eye. Although her bilateral temporal arteries were palpable and rope-like, color Doppler ultrasonography showed normal flow in both arteries with no signs of arteritis. MRI revealed increased enhancement of the pachymeninges enveloping both cerebral hemispheres, suggestive of hypertrophic pachymeningitis.Conclusion: Symptoms and laboratory data are similar for both hypertrophic pachymeningitis and giant cell arteritis (GCA). The present case suggests the utility of ultrasonography and MRI as rapid, convenient, and noninvasive tools for differential diagnosis of optic neuropathy.

[A case of possible elderly onset rheumatoid meningitis without arthritis]

A 93-year-old man was admitted to our hospital with disturbance of consciousness. Brain magnetic resonance imaging (MRI) showed hyperintensity of the subarachnoid space in the left frontal and parietal lobes on diffusion weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR). Gadolinium-enhancement of the pia mater was also observed. We did not perform biopsy because of a high risk of perioperative complication. Although physical examination found no evidence of the rheumatoid arthritis, rheumatoid factors and anti-cyclic citrullinated peptides antibodies were elevated. He was suspected to have rheumatoid meningitis. We treated him with intravenous methylprednisolone (0.5 g/day) for 3 days. Rheumatoid meningitis often shows hyperintensity of the subarachnoid space on the DWI and FLAIR, and steroid therapy is effective.

Methotrexate-associated primary hepatic lymphoma and cranial neuropathy in a patient with rheumatoid arthritis: A case report with clinical follow-up over a 7-year period

RATIONALE

Rheumatoid arthritis (RA) shows a variable clinical expression in patients. Articular disease is common manifestation, but patients may rarely present with extra-articular manifestation such as cranial neuropathy. Also, primary hepatic lymphoma (PHL) has rarely been reported in patient treated with immunosuppressive drug such as methotrexate (MTX) for RA. We herein describe a case of cranial neuropathy and MTX-related PHL in a woman receiving MTX for RA.

PATIENT CONCERNS

A 73-year-old women received MTX treatment for more than 5 years, presented with recurrent cranial neuropathies. During therapy of cranial neuropathies, liver enzyme levels were elevated.

DIAGNOSES

The patient was diagnosed as RA by laboratory examination. A series of examinations had been launched to evaluate any possible cause of the extra-articular manifestation of the patient including ultrasound, computed tomography, magnetic resonance image (MRI) and positron emission tomography of the liver and MRI of the brain. Finally, the patient diagnosed as MTX-associated PHL and cranial neuropathy.

INTERVENTIONS

The patient underwent 4-year MTX therapy for RA at first with prednisolone. After that, she had been treated with cyclophosphamide therapy for cranial neuropathy. The liver biopsy was performed for hepatic lesion.

OUTCOMES

MTX was discontinued, but no improvement of PHL and elevated liver enzyme was observed during the 3 weeks. The patient received 6 cycles of chemotherapy for 3 months and achieved complete remission including PHL and cranial neuronal lesion with symptom. No instances of relapse have occurred in 2 years of follow-up.

LESSONS

The present case is the extremely rare case in which MTX-related PHL and cranial neuropathy were involved together in the RA patient. It is necessary to examine long-term follow up hepatic and neurologic examinations that patient had a long history of receiving MTX therapy for RA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A case of anti-cyclic citrullinated peptides antibody positive rheumatoid meningitis without arthritis at the onset of neurological symptoms

We report an 84-year-old woman with rheumatoid meningitis. She developed weakness in her muscles and became cognitively impaired. However, physical examination revealed no evidence of rheumatoid arthritis. Levels of anti-cyclic citrullinated peptide antibodies were elevated. Brain magnetic resonance imaging (MRI) showed hyperintense lesions in the frontotemporoparietal subarachnoid space on fluid attenuated inversion recovery (FLAIR) images. Leptomeningeal enhancement was also evident on gadolinium-enhanced T1-weighted images. We suspected rheumatoid meningitis. A brain biopsy was performed and methylprednisolone pulse therapy was started. Subsequently, her symptoms and MRI findings rapidly improved.

Immunotherapies for Neurological Manifestations in the Context of Systemic Autoimmunity

Neurological involvement is relatively common in the majority of systemic autoimmune diseases and may lead to severe morbidity and mortality, if not promptly treated. Treatment options vary greatly, depending on the underlying systemic pathophysiology and the associated neurological symptoms. Selecting the appropriate therapeutic scheme is further complicated by the lack of definite therapeutic guidelines, the necessity to differentiate primary neurological syndromes from those related to the underlying systemic disease, and to sort out adverse neurological manifestations caused by immunosuppressants or the biological agents used to treat the primary disease. Immunotherapy is a sine qua non for treating most, if not all, neurological conditions presenting in the context of systemic autoimmunity. Specific agents include classical immune modulators such as corticosteroids, cyclophosphamide, intravenous immunoglobulin, and plasma exchange, as well as numerous biological therapies, for example anti-tumor necrosis factor agents and monoclonal antibodies that target various immune pathways such as B cells, cytokines, and co-stimulatory molecules. However, experience regarding the use of these agents in neurological complications of systemic diseases is mainly empirical or based on small uncontrolled studies and case series. The aim of this review is to present the state-of-the-art therapies applied in various neurological manifestations encountered in the context of systemic autoimmune diseases; evaluate all treatment options on the basis of existing guidelines; and compliment these data with our personal experience derived from a large number of patients.

Neuro-Behçet's Disease Presenting as Hypertrophic Pachymeningitis

A 25-year-old man presented with blurred vision and chronic headache. His brain MRI revealed bilateral frontal pachymeningeal enhancement with leptomeningeal enhancement. The patient had experienced recurrent oral ulcer and had anterior uveitis and papulopustules skin lesion. We diagnosed him with hypertrophic pachymeningitis (HP) associated with neuro-Behçet's disease (NBD). There have been few reports describing HP in patients with NBD. We report a case of NBD presenting as HP.

Neurology of rheumatologic disorders

Rheumatologic diseases encompass autoimmune and inflammatory disorders of the joints and soft tissues that often involve multiple organ systems, including the central and peripheral nervous systems. Common features include constitutional symptoms, arthralgia and arthritis, myalgia, and sicca symptoms. Neurological manifestations may present in patients with preexisting rheumatologic diagnoses, occur concurrently with systemic signs and symptoms, or precede systemic manifestations by months to years. Rheumatic disorders presenting as neurological syndromes may pose diagnostic challenges. Advances in immunosuppressive treatment of rheumatologic disease have expanded the treatment armamentarium. However, serious neurotoxic effects have been reported with both old and newer agents. Familiarity with neurological manifestations of rheumatologic diseases, diagnosis, and potential nervous system consequences of treatment is important for rapid diagnosis and appropriate intervention. This article briefly reviews the diverse neurological manifestations and key clinical features of rheumatic disorders and the potential neurological complications of agents commonly used for treatment.

Idiopathic hypertrophic spinal pachymeningitis

Spinal idiopathic hypertrophic pachymeningitis (IHP) is a rare, chronic, nonspecific, granulomatous inflammatory disorder of the dura with unknown etiology. It can cause a localized or diffuse thickening of the dura mater with compression of the spinal canal and possible myelopathic symptoms. The authors report 3 consecutive cases of spinal IHP with a review of the literature. The diagnosis of spinal IHP was based on biopsy and pathological confirmation. Typical MR imaging findings suggestive of spinal IHP were noted in all cases. The clinical course may be marked by deterioration despite conservative therapy and may require surgical intervention to prevent irreversible neurological damage. Therefore, prompt diagnosis and institution of proper treatment is critical.

Idiopathic Hypertrophic Cranial Pachymeningitis Associated With Intermediate Uveitis

The authors report a case with idiopathic hypertrophic cranial pachymeningitis associated with intermediate uveitis. The patient complained of decreased vision in both eyes, especially the right. Ophthalmic examination revealed right optic disc pallor, bilateral vitritis, and cystoid macular edema. Magnetic resonance imaging revealed marked enhancement of a dural lesion. The macular edema responded well to medical treatment. Intermediate uveitis has not yet been reported in the context of idiopathic hypertrophic cranial pachymeningitis.

Rheumatoid leptomeningitis: magnetic resonance imaging and pathologic findings--a case report

BACKGROUND AND PURPOSE

Rheumatoid arthritis (RA) is a chronic inflammatory multisystem disease with articular and extra-articular manifestations. Intracranial manifestations of RA are rare. Purpose of this article is to report on a rarely described leptomeningeal involvement in RA, and on its neuroimaging features, including diffusion-weighted imaging (DWI).

METHODS

The authors describe the case of a 74-year-old woman with a 5-year history of RA presenting with progressive left-side weakness and hypoesthesia. The patient underwent laboratory investigation and brain contrast-enhanced MRI, also with DWI, before undergoing brain biopsy.

RESULTS

Neuroimaging revealed abnormal high T2-signal in right frontal and parietal lobes, restricted diffusion in the subarachnoid space, and diffuse thick linear leptomeningeal contrast-enhancement. These findings were interpreted as rheumatoid leptomeningitis, and brain biopsy confirmed this diagnosis.

CONCLUSIONS

In summary, rheumatoid meningitis is a rare neurological complication of RA, but it should be considered in the proper clinical setting when patient presentation and laboratory results fail to support the other differential diagnostic possibilities proposed by the MR imaging findings.

An unusual central nervous system involvement in rheumatoid arthritis: combination of pachymeningitis and cerebral vasculitis

Severe primary central nervous system (CNS) involvement such as vasculitis and pachymeningitis can rarely occur in rheumatoid arthritis (RA) even in the absence of systemic disease activation. The authors illustrate a female patient with well-controlled RA who presented with headaches, encephalopathy, seizures and relapsing focal neurological deficits. Primary rheumatoid cerebral vasculitis and pachymeningitis were diagnosed based on suggestive brain magnetic resonance (MR) imaging, MR angiography, cerebrospinal fluid analysis and cerebral angiography. MR showed abnormal leptomeningeal enhancement and hyperintense FLAIR signal in the cortical subarachnoid spaces consistent with pachymeningitis. Cerebral angiography findings were consistent with vasculitis. Aggressive treatment resulted in significant clinicoradiological resolution. Cerebral vasculitis is a rare but certain manifestation of RA. This complication can be diagnosed in the presence of suggestive angiographic and CSF findings. The condition may be steroid resistant, and needs to be treated more aggressively.

Rheumatoid cranial pachymeningitis successfully treated with long-term corticosteroid

We report a 68-year-old man without clinical history of rheumatoid arthritis who presented with acute bilateral palsy of the IX and X cranial nerves secondary to pachymeningitis confirmed on cranial MRI. Rheumatoid factor in both serum and cerebrospinal fluid and anti-agalactosyl IgG antibody in serum were positive. The radiographs of hands and feet revealed signs of early rheumatism. The dural biopsy specimen showed chronic inflammation with infiltration of lymphocytes and histiocytes. A diagnosis of rheumatoid cranial pachymeningitis was made. Treatment with long-term corticosteroid was excellently effective.

Optic Neuropathy Associated With Periostitis in Relapsing Polychondritis

Optic neuropathy is an uncommon manifestation of relapsing polychondritis (RPC), a rare systemic disease affecting cartilaginous and proteoglycan-rich structures. The optic neuropathy has been attributed to ischemia, intrinsic inflammation of the optic nerve, or spread of inflammation to the nerve from adjacent intraconal orbital tissues. We report a case of recurrent corticosteroid-responsive optic neuropathy in which MRI did not show ocular, optic nerve, or intraconal orbital abnormalities but did show periosteal thickening and enhancement in the apical orbit and adjacent intracranial space consistent with periostitis. The periostitis, which is a manifestation of a systemic vasculitis or an autoimmune reaction to progenitors of cartilage, probably caused the optic neuropathy by compression or inflammation. It is important to recognize this mechanism of optic neuropathy as its imaging features may be a subtle yet critical clue to an underlying systemic condition that can be life-threatening if not properly managed.

CD8+ T lymphocytes infiltrate predominantly in the inflammatory foci of MPO-ANCA-positive thoracic hypertrophic pachymeningitis in a patient with HLA-A24

Hypertrophic pachymeningitis (HP) is extremely rare and an inflammatory process that thickens the dura mater. A 59-year-old Japanese woman developed backache, became paraplegic, and magnetic resonance imaging revealed diffuse thickening of the thoracic dura mater encompassing the spinal cord. Although a test for myeloperoxidase antineutrophil cytoplasmic autoantibody (MPO-ANCA) was shown to be positive, vasculitis was not found and CD8(+) T lymphocytes that predominated in the inflammatory foci. Both interleukin (IL)-2 and IL-6 were markedly elevated in not only sera but also cerebrospinal fluids, very much higher in the latter. Human leukocyte antigen (HLA) typing revealed A24 positivity, suggesting this molecule was interacting with CD8(+) T lymphocytes. It was suggested that immunological disharmony and autoimmunity would play a pivotal role in the development of HP under genetic background of HLA-A24, and HP would be one feature of multiple organ involvement in ANCA-associated diseases.

Neurological involvement in patients with rheumatic disease

Patients with multi-system rheumatic conditions may have disease affecting the central and peripheral nervous systems. Early assessment is often helpful in averting the development of serious complications, which in some conditions can be prevented by the prompt institution of treatment. We review the spectrum of neurological disease in patients with a rheumatological diagnosis. The wide variety of associated neurological complications is discussed in the context of specific rheumatic conditions, varying from spinal cord involvement in rheumatoid arthritis, to neuropsychiatric involvement in systemic lupus erythematosus and neurological sequelae in vasculitic disorders. We discuss diagnostic criteria and recommended management options (where available), and describe the role of new tools such as functional brain imaging in the diagnosis and monitoring of disease. We also discuss the potential for development of neurological complications from the use of anti-rheumatic drugs.

Clinical aspects of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown etiology affecting both articular tissues and extraarticular organs. The disease is often progressive and results in pain, stiffness, and swelling of joints culminating in significant morbidity and increased mortality. This chapter discusses the epidemiology, possible etiology, clinical manifestations, diagnostic approach and treatment options of RA.

[Normal and abnormal meningeal enhancement: MRI features]

The authors describe normal imaging of the meninges and meningeal spaces and MR (magnetic resonance) imaging findings in tumoral and nontumoral diseases. Dural or/and pial enhancement may be related to tumoral, infectious or granulomatous diseases.

A case of ANCA-associated vasculitis with predominant involvement of central nervous system

The authors present a peculiar case of a 53-year-old woman affected by ANCA-associated vasculitis with prevailing involvement of the central nervous system. Diagnosis was really difficult.