Rheumatoid Meningitis: Diagnostic and Therapeutic Observations

Conn Med. 2016 Mar;80(3):163-6.

Abstract

A 75-year-old female with untreated rheumatoid arthritis presented with two weeks of behavioral changes and cognitive decline. A neurologic examination showed severe encephalopathy, brisk reflexes, and bilateral Babinski sign. A contrast-enhanced brain MRI demonstrated right meningeal enhancement and periventricular white matter disease. A computed tomographic angiogram (CTA) of the head and neck was negative for vasculitis. The cerebrospinal fluid (CSF) demonstrated lymphocytic pleocytosis. The patient's serum rheumatoid factor levels were elevated. A biopsy of the leptomeninges and cortex showed lymphocytic vasculitis of the cortical tissue and patchy lymphoplasmacytic infiltrates of dural small vessels consistent with rheumatoid meningitis. The patient received pulse-dose steroids followed by cyclophosphamide infusions. At her three month follow-up appointment, the patient's mental status had improved mildly. A follow-up brain MRI showed resolution of enhancement, but progression of subcortical bihemispheric white matter disease. Subsequently, the patient developed a respiratory infection and passed away. In rheumatoid arthritis, symptoms of encephalopathy, headaches, seizures, or focal neurologic deficits should raise suspicion for CNS involvement. This potentially treatable disease warrants prompt diagnosis.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Antirheumatic Agents / administration & dosage
  • Arthritis, Rheumatoid / complications*
  • Behavioral Symptoms / etiology
  • Cognition Disorders / etiology
  • Cyclophosphamide / administration & dosage*
  • Fatal Outcome
  • Female
  • Glucocorticoids / administration & dosage*
  • Humans
  • Magnetic Resonance Imaging
  • Meningitis* / diagnosis
  • Meningitis* / etiology
  • Meningitis* / psychology
  • Meningitis* / therapy
  • Neurologic Examination / methods
  • Respiratory Tract Infections / complications*
  • Tomography, X-Ray Computed

Substances

  • Antirheumatic Agents
  • Glucocorticoids
  • Cyclophosphamide