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Fan S, Zhao J, Hou B, Liu M, Niu J, Zhou Y, Mao C, Ren H, Feng F, Li M, Zeng X, Zhu Y, Guan H. Rheumatoid meningitis: a rare neurological complication of rheumatoid arthritis. Front Immunol 2023; 14:1065650. [PMID: 37350975 PMCID: PMC10282747 DOI: 10.3389/fimmu.2023.1065650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/19/2023] [Indexed: 06/24/2023] Open
Abstract
Objective To describe the clinical and neuroimaging characteristics of rheumatoid meningitis (RM) in Chinese patients. Methods The patients admitted to our hospital with the diagnosis of RM in the past 8 years were retrospectively analyzed. Results Six patients with RM were identified among 933 patients admitted with rheumatoid arthritis (RA). The symptoms of meningitis occurred after onset of arthritis in five patients and before onset in one. Headache (n=6), hyperacute focal neurological deficits (n=4) and seizures (n=3) were the most prevalent symptoms. The nadir modified Rankin Scale score was ≥3 in five patients. Rheumatoid factor was elevated in all patients, and interleukin-6 levels in cerebrospinal fluid were dramatically elevated in three of four tested patients. Magnetic resonance imaging of the brain revealed that the meninges were affected in all patients and the cerebral parenchyma was affected in one patient. The lesions were generally located in the frontoparietal region and showed restricted diffusion along the adjacent subarachnoid space. RM occurred during disease-modifying therapy in four patients. In the acute episode, three patients improved on tocilizumab and the other three improved on pulse corticosteroids. For maintenance therapy, two patients received combined therapy of tocilizumab and other immunosuppressive agents, one received adalimumab and methotrexate, and two received low-dose oral corticosteroids with an immunosuppressive agent. Five patients had a good outcome, and one died of Pneumocystis jirovecii pneumonia after stabilization of his neurologic conditions. No relapse of RM occurred on immunotherapy during follow-up. Conclusions Chinese patients with RM share some remarkable clinical and neuroimaging features and respond well to appropriate immunotherapy. Tocilizumab could be a treatment option for this severe complication of RA.
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Affiliation(s)
- Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingwen Niu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Zhou
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenhui Mao
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yicheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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2
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Owens M, Gatson NT, Mongelluzzo G, Goren O, Newman E, Sandulescu MC. Secondary Normal-Pressure Hydrocephalus in Rheumatoid Meningitis. Case Rep Neurol 2021; 13:434-440. [PMID: 34326752 PMCID: PMC8299371 DOI: 10.1159/000514728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022] Open
Abstract
Normal-pressure hydrocephalus (NPH) is a common cause of gait apraxia, cognitive impairment, and urinary incontinence in the elderly. It is usually a primary idiopathic disorder but can be secondary. We present a case of secondary NPH due to biopsy-confirmed rheumatoid meningitis initially refractory to intravenous (IV) immunotherapy. Our patient reported an excellent response right after shunting. Her gait remains normal one and a half years later. We searched PubMed for similar cases of rheumatoid meningitis with gait abnormality for additional clinicopathologic discussion. The patient's movement disorder initially improved with steroid taper. However, she developed progressive symptoms, later on, refractory to IV solumedrol and rituximab. She underwent ventriculoperitoneal shunting (VPS) and reported an outstanding outcome. This is the first reported biopsy-confirmed case of rheumatoid meningitis causing NPH to undergo shunting for immediate improvement. Previous cases of rheumatoid meningitis-associated Parkinsonism have improved with steroid induction. Although our patient's rheumatoid arthritis is now controlled, her case illustrates that NPH in autoinflammatory conditions may not recover with immune suppression alone. VPS is an option for a faster response in secondary NPH due to rheumatoid meningitis or other inflammatory disorders with progressive symptoms despite standard induction therapy.
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Affiliation(s)
- Micaela Owens
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Na Tosha Gatson
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Gino Mongelluzzo
- Department of Radiology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Eric Newman
- Department of Rheumatology, Geisinger Medical Center, Danville, Pennsylvania, USA
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3
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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: 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.
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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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4
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Lapides DA, McDonald MM. Inflammatory Manifestations of Systemic Diseases in the Central Nervous System. Curr Treat Options Neurol 2020; 22:26. [PMID: 32834714 PMCID: PMC7387810 DOI: 10.1007/s11940-020-00636-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review presents the current recommended therapeutic interventions for inflammatory disease in the central nervous system (CNS) secondary to systemic diseases of immune dysregulation. Treatment recommendations for CNS inflammation associated with rheumatologic conditions, immune-related adverse effects from immune checkpoint inhibitors (ICIs), and demyelinating disease from tumor necrosis factor-α (anti-TNFs) are explored. Additional therapeutic options for inflammation related to postviral syndromes and genetic immunodeficiencies are also discussed. RECENT FINDINGS In addition to treatment of mild, moderate, and severe CNS rheumatologic disease as guided by the European League Against Rheumatism (EULAR), early consideration of rituximab for severe IgG4-related disease and induction with anti-TNF therapy for severe neurosarcoidosis should be considered. Although often not first line, treatment options for CNS inflammatory diseases based on disease mechanism are emerging, including tocilizumab for Behcet's disease, natalizumab for ICI associated autoimmune encephalitis, and abatacept for treatment of infiltrative disease secondary to CTLA-4 deficiency. Hematopoietic stem cell treatments represent highly efficacious but risky options for autoimmunity related to genetic immunodeficiency. SUMMARY While early high dose steroids remains first line therapy for most CNS inflammatory conditions, a rapidly expanding arsenal of immune targeted therapies offers clinicians tailored disease specific options for treatment.
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Affiliation(s)
- David A. Lapides
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
| | - Mark M. McDonald
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
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5
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Rodriguez Alvarez M, Rodríguez Valencia LM, Seidman R, Acharya A, Espina N, Ravindran N, Mishan D, Mesa CJ, Espinoza LR, McFarlane IM. Rheumatoid meningitis and infection in absence of rheumatoid arthritis history: review of 31 cases. Clin Rheumatol 2020; 39:3833-3845. [PMID: 32519051 DOI: 10.1007/s10067-020-05221-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 12/17/2022]
Abstract
A 62-year-old healthy male presents with leg weakness and fever. Imaging revealed leptomeningeal enhancement (LE). After cerebrospinal fluid (CSF) cultures were negative, he was discharged with a diagnosis of aseptic meningitis, but was readmitted due to worsening symptoms. Brain biopsy suggested rheumatoid leptomeningitis associated with elevated serum rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibodies (ACPA). Following discharge, the New York State Department of Health (NYSDOH) reported a polymerase chain reaction (PCR) on CSF and brain DNA consistent with Naegleria fowleri (NF). After dramatic improvement on steroids, the patient declined antimicrobial treatment. Upon prednisone taper, symptoms recurred which responded to rituximab (RTX). This case highlights a possible association between rheumatoid leptomeningitis (RM) onset and infection, in a patient without a history of rheumatoid arthritis (RA). Our goal is to assess whether this association is present in 69 RM cases reported since 2000. We also describe diagnosis and treatment of 31 new cases (January 2017 to March 2020). We did not identify evidence of active/latent infection in patients with RM and previous RA; however, patients without RA history appeared to have a significantly higher rate. This finding could demonstrate the necessity of evaluating for infection in de novo RM cases without antecedent RA history. We also describe characteristic clinical patterns for each group. More studies are needed to corroborate these results and expand into a possible distinct natural history of RM in each group, which might have an impact upon the clinical outcome.
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Affiliation(s)
- Milena Rodriguez Alvarez
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA. .,School of Graduate Studies, SUNY-Downstate Medical Center, Brooklyn, NY, 11203, USA.
| | | | - Roberta Seidman
- Department of Pathology, Stony Brook University Hospital, Stony Brook, NY, 11794, USA
| | - Ajita Acharya
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA
| | - Noel Espina
- Department of Health, Wadsworth Center, New York State, Albany, NY, 12237, USA
| | - Nadish Ravindran
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA
| | - Daniel Mishan
- School of Graduate Studies, SUNY-Downstate Medical Center, Brooklyn, NY, 11203, USA
| | - Christopher J Mesa
- Department of Internal Medicine, Division of Rheumatology, Louisiana State University Health Science Center New Orleans, New Orleans, LA, 70006, USA
| | - Luis R Espinoza
- Department of Internal Medicine, Division of Rheumatology, Louisiana State University Health Science Center New Orleans, New Orleans, LA, 70006, USA
| | - Isabel M McFarlane
- Department of Internal Medicine, Division of Rheumatology, SUNY-Downstate Medical Center, Health & Hospitals Kings County, Brooklyn, NY, 11201, USA
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Kira Y, Shibata KI, Inamizu S, Nakagaki H, Nagano S. [A case of possible elderly onset rheumatoid meningitis without arthritis]. Rinsho Shinkeigaku 2019; 59:520-524. [PMID: 31341127 DOI: 10.5692/clinicalneurol.cn-001296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Yuichi Kira
- Department of Neurology, Fukuoka City Hospital.,Department of Neurology, Kyushu University Graduate School of Medicine
| | | | - Saeko Inamizu
- Department of Neurology, Fukuoka City Hospital.,Department of Neurology, Kyushu University Graduate School of Medicine
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7
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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.
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Affiliation(s)
- Kaoru Yagita
- Department of Neurology, Tenri Hospital, Tenri, Nara, Japan
| | - Akiyo Shinde
- Department of Neurology, Tenri Hospital, Tenri, Nara, Japan
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8
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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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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: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/07/2019] [Indexed: 11/26/2022] Open
Abstract
Rheumatoid meningitis is a rare complication of rheumatoid arthritis (RA). It is associated with substantial morbidity and mortality. The condition may present in a variety of ways and is therefore diagnostically challenging. Uncertainty still exists regarding the optimal treatment strategy. Herein, we describe the case of a 74-year-old man with a history of well-controlled seropositive RA on low-dose prednisone, hydroxychloroquine, and methotrexate. The patient presented with a several-month history of multiple prolonged episodes of expressive aphasia, right hemiparesis, and encephalopathy. Although no epileptiform activity was recorded on repeated electroencephalography, the symptoms fully resolved following treatment with antiepileptic drugs. He subsequently developed acute asymmetrical parkinsonism of the right hemibody. Magnetic resonance imaging revealed subtle enhancement of the leptomeninges over the left frontoparietal convexity. Cerebrospinal fluid analysis revealed a mild lymphocytic pleocytosis and elevated proteins. Histopathologic analysis of a meningeal biopsy revealed nodular rheumatoid meningitis. The patient was treated with corticosteroids and cyclophosphamide, following which he incompletely recovered. This is the first description of rheumatoid meningitis manifesting with acute parkinsonism and protracted non-convulsive seizures. A summary of cases reported since 2005, including data on pathology, therapy and outcomes, along with a discussion on the efficacy of different treatment strategies are provided.
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Affiliation(s)
- David Pellerin
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Michael Wodkowski
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Marie-Christine Guiot
- Department of Pathology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Hisham AlDhukair
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada.,Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Andrea Blotsky
- Division of General Internal Medicine, Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Jason Karamchandani
- Department of Pathology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Evelyne Vinet
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Anne-Louise Lafontaine
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Stuart Lubarsky
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada.,Centre for Medical Education, Faculty of Medicine, McGill University, Montreal, QC, Canada
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10
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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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11
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Boban J, Ardalı S, Thurnher MM. Leptomeningeal form of Immunoglobulin G4-related hypertrophic meningitis with perivascular spread: a case report and review of the literature. Neuroradiology 2018; 60:769-773. [PMID: 29736618 PMCID: PMC5995998 DOI: 10.1007/s00234-018-2028-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/24/2018] [Indexed: 12/24/2022]
Abstract
Purpose Immunoglobulin G4 (IgG4)-related disease represents a spectrum of fibro-inflammatory disorders that affects various organ systems, including the central nervous system. Methods Here we present the case of lgG4-related hypertrophic meningitis with exclusively leptomeningeal involvement and spread via perivascular spaces. Results A 58-year-old male patient presented with complex partial seizures. Initial computed tomography examination showed left frontal sulcal hyperdensity. Subsequent magnetic resonance examination revealed FLAIR hyperintensity in the central sulcus, with post-contrast enhancement in the form of “dotted line.” Physical examination, routine laboratory, and cerebrospinal fluid analyses were unremarkable. Meningeal biopsy confirmed IgG4-related meningitis. After corticosteroid treatment, a complete resolution of imaging findings was observed. Two months later, the patient presented with relapsing neurological symptoms and radiological findings in postcentral, precentral, and temporal sulci, resembling the form of “dotted line” contrast enhancement. In addition, linear intraparenchymal enhancement that followed perivascular spaces was seen in the left parietal lobe. After repeated steroid therapy, all lesions resolved completely. Conclusion We reported the first case of isolated IgG4-related leptomeningeal involvement with a “dotted line” enhancement and perivascular intraparenchymal spread. Although IgG4-related meningitis represents a rare disease, both clinicians and radiologists should include this condition in the differential diagnosis of unclear leptomeningeal disease.
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Affiliation(s)
- Jasmina Boban
- Faculty of Medicine, Department for Radiology, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
| | - Selin Ardalı
- Department of Radiology, Hacettepe University Faculty of Medicine, Sıhhiye, 06100, Ankara, Turkey
| | - Majda M Thurnher
- Section of Neuroradiology and Musculoskeletal Radiology, Department for Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Shibahara T, Matsushita T, Matsuo R, Fukushima Y, Fukuda K, Sugimori H, Kamouchi M, Kitazono T, Ago T. Anti-Cyclic Citrullinated Peptide Antibody-Positive Meningoencephalitis in the Preclinical Period of Rheumatoid Arthritis. Case Rep Neurol 2016; 8:156-160. [PMID: 27721779 PMCID: PMC5043166 DOI: 10.1159/000447627] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 06/14/2016] [Indexed: 11/19/2022] Open
Abstract
Rheumatoid meningoencephalitis (RM) is a rare complication of rheumatoid arthritis (RA). This report describes a 63-year-old man with complaints of high-grade fever, headache, and vomiting for several days before admission. Both his serum and cerebrospinal fluid were positive for anti-cyclic citrullinated peptide (CCP) antibody and rheumatoid factor, and contrast-enhanced fluid-attenuated inversion recovery magnetic resonance imaging (MRI) showed abnormal gadolinium enhancement of the meninges and high-intensity lesions in the subarachnoid spaces. The patient was diagnosed with RM despite lack of signs suggesting RA. His symptoms drastically improved with intravenous infusion of high-dose methylprednisolone. Two months later, he developed RA. The findings in this patient suggest that RM could develop prior to the onset of RA. Anti-CCP antibody and MRI findings may be useful for the diagnosis of RM, regardless of RA history.
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Affiliation(s)
- Tomoya Shibahara
- Division of Cerebrovascular Medicine, St. Mary's Hospital, Kurume, Japan; Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Ryu Matsuo
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Kenji Fukuda
- Division of Cerebrovascular Medicine, St. Mary's Hospital, Kurume, Japan
| | | | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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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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14
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Kawabata Y, Miyaji Y, Nakano T, Joki H, Tanaka F. [Aseptic meningitis in a patient with cerebrospinal fluid anti-agalactosyl IgG antibody-positive preclinical rheumatoid arthritis: a case report]. Rinsho Shinkeigaku 2015; 55:904-8. [PMID: 26511025 DOI: 10.5692/clinicalneurol.cn-000754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 69-year-old woman presented with non-fluent aphasia, ideomotor apraxia, right hemiparesis and convulsion. Her medical history was unremarkable, and she had not suffered from arthritis. DWI and FLAIR image of brain MRI showed hyperintensities in the subarachnoid space along the left frontal and both parietal lobes, and these lesions were associated with gadolinium enhancement. The levels of serum anti-cyclic citrullinated peptide antibody, anti-agalactosyl IgG antibody and matrix metalloproteinase-3 were elevated. The results of blood cultures were negative. Cerebrospinal fluid (CSF) analysis revealed monocytic pleocytosis and negative findings for infection or malignancy. The level of anti-agalactosyl IgG antibody in CSF was elevated. The antibody index (AI) of anti-agalactosyl IgG antibody (the ratio between the CSF/serum quotient for IgG antibodies, and the CSF/serum quotient for total IgG; normal value of AI < 1.3) showed considerably high value of 8.4, indicating the intrathecal-specific antibody synthesis. As a result, the pathogenesis of her disease was consistent with rheumatoid meningitis despite lack of arthritis. After intravenous administration of methylprednisolone, her symptoms, the level of anti-agalactosyl IgG antibody in CSF, and the MRI findings were ameliorated. Anti-agalactosyl IgG antibody in the CSF was a helpful biomarker in diagnosis and assessment of the severity of rheumatoid meningitis.
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Affiliation(s)
- Yuichi Kawabata
- Department of Neurology and Stroke Medicine, Yokohama Sakae Kyosai Hospital
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15
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Lu L, Chwalisz B, Pfannl R, Narayanaswami P. Rheumatoid meningitis: a rare complication of rheumatoid arthritis. BMJ Case Rep 2015; 2015:bcr-2014-208745. [PMID: 26135486 DOI: 10.1136/bcr-2014-208745] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of a 60-year-old Caucasian woman with a 23-year history of rheumatoid arthritis, who presented with a 2-week history of headache and cognitive/behavioural changes. On the basis of clinical features, radiology, laboratory data and meningeal biopsy, a diagnosis of rheumatoid meningitis was performed. High-dose intravenous methylprednisolone was used as initial treatment followed by oral prednisone. The patient's symptoms improved and repeat MRI scans confirmed resolution of the meningeal lesions. The clinical diagnosis of rheumatoid meningitis is difficult, but it must be considered in patients with long-standing rheumatoid arthritis presenting with neurological symptoms. Glucocorticoids or other immunomodulatory therapy are the mainstay of treatment.
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Affiliation(s)
- Lin Lu
- School of Medicine, Imperial College London, London, Greater London, UK William Harvey Hospital, Ashford, Kent, UK
| | - Bart Chwalisz
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Rolf Pfannl
- Department of Pathology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
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16
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Morimoto S, Takao M, Sakurai K, Sunagawa M, Komiya T, Arai T, Kanemaru K, Murayama S. [Steroid responsive chronic meningoencephalitis reminiscent of rheumatoid meningitis: a case report]. Rinsho Shinkeigaku 2015; 55:573-9. [PMID: 26084231 DOI: 10.5692/clinicalneurol.cn-000720] [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
A 62-year-old woman presented at our hospital with a headache, cognitive decline, and fever that had persisted for 3 months. On admission, fever, headache, and mild cognitive dysfunction were all clearly evident, suggesting chronic meningoencephalitis. Laboratory examination showed mild neutrophilia as well as an increase in her erythrocyte sedimentation rate and serum C-reactive protein levels. MRI showed multiple small hyperintense lesions on T2 weighted image and diffusion weighted image (DWI) in the cerebral cortex and white matter. Contrast-enhanced T1 weighted image showed the abnormal pial enhancement along the cerebral sulci. Systemic evaluations for infectious organisms, autoantibodies, and malignant tumors were all negative. Her fever and neurological symptoms continued. As a result of worsening MRI findings, a brain biopsy was carried out. Neuropathological analysis revealed neutrophilic infiltration in the subarachnoid space and multinucleated giant cells. However, there was no vasculitis on the histological sections. This pathological finding was reminiscent of rheumatoid meningitis despite articular findings of rheumatoid arthritis, as well as rheumatoid factor (RF) and anti-CCP antibody tests being negative. After oral steroid therapy, her fever and inflammatory reactions by laboratory test diminished and her cognitive function improved remarkably.
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Affiliation(s)
- Satoru Morimoto
- Department of Neurology, Tokyo Metropolitan Geriatric Hospital and Institution of Gerontology
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Redefining a diagnosis: from meningeal plasma cell granuloma to rheumatoid meningitis. Report of a patient follow-up. Neurol Sci 2015; 36:1047-8. [PMID: 25596712 DOI: 10.1007/s10072-015-2075-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/09/2015] [Indexed: 10/24/2022]
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18
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Bourgeois P, Rivest J, Bocti C. Rheumatoid meningitis presenting with stroke-like episodes. Neurology 2014; 82:1564-5. [PMID: 24647026 DOI: 10.1212/wnl.0000000000000366] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neurologic symptoms in patients with rheumatoid arthritis (RA) are most often caused by osseous compression, affecting the cervical spine or peripheral neurologic structures. CNS involvement in RA is infrequent, consisting of CNS vasculitis or meningitis with or without meningeal nodules.(1) When meningeal infiltration is seen, symptoms of presentation can include focal neurologic deficits, seizure, cranial nerve dysfunction, or altered consciousness.(1) Here we describe a patient with an unusual presentation of rheumatoid meningitis.
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