1
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Khan O, Aslam S, Mohammadrezaei F, Wilches RDM, Mehrabi J, Yehounatan M, Kumari S, Singh S, Ahmadi M, Masri D, Konka S, Margulis Y. New-onset seizures: an unusual neurologic manifestation of rheumatoid arthritis. Oxf Med Case Reports 2024; 2024:omad159. [PMID: 38370505 PMCID: PMC10873692 DOI: 10.1093/omcr/omad159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/16/2023] [Accepted: 12/08/2023] [Indexed: 02/20/2024] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory condition primarily affecting the musculoskeletal system but can often involve other organ systems as well. Rheumatoid meningitis is a rare central nervous system (CNS) manifestation of RA characterized by pachymeningeal and leptomeningeal enhancement. Herein, we present a case of a 64-year-old male who presented with left lower extremity weakness and witnessed seizures. The diagnostic work-up, including lumbar puncture, brain MRI and meningeal biopsy ruled out malignancy and were consistent with the diagnosis of rheumatoid meningitis. The patient was discharged on high-dose steroids along with anti-seizure medications. On subsequent follow-up visits, the patient remained seizure-free.
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Affiliation(s)
- Omair Khan
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Sadia Aslam
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | | | | | - Joseph Mehrabi
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | | | - Sapna Kumari
- Department of Medicine, Ross University School of Medicine, Bridgetown, Barbados
| | - Sehajpreet Singh
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Maryam Ahmadi
- Department of Pathology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Daniel Masri
- Department of Radiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Sarita Konka
- Division of Rheumatology, Maimonides Medical Center, Brooklyn, NY, USA
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2
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Aktan Suzgun M, Erener N, Cavus GH, Ozdede A, Guner S, Ugurlu S, Comunoglu N, Kizilkilic O, Saip S. A review of rheumatoid meningitis with case studies. Mod Rheumatol Case Rep 2023; 7:340-346. [PMID: 36718604 DOI: 10.1093/mrcr/rxad010] [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: 11/15/2022] [Revised: 12/17/2022] [Accepted: 01/04/2023] [Indexed: 02/01/2023]
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease involving synovial joints, and it is known that extra-articular manifestations that may affect the central and peripheral nervous systems may develop during its course. Rheumatoid meningitis is very rare among all neurological involvements. In this study, cases diagnosed as rheumatoid meningitis with clinical, imaging, laboratory, and histopathological features are presented, and the aim of the study is to present current approaches in the diagnosis and treatment of rheumatoid meningitis in the light of case studies and current literature. The data of the patients who were followed up with the diagnosis of rheumatoid meningitis in neurology clinic between 2017 and 2021 were reviewed retrospectively. Three cases diagnosed with rheumatoid meningitis are presented in detail. In the first case, the diagnosis was reached by clinical, imaging, and laboratory findings as well as treatment response, while the diagnosis was made by histopathological verification in the second case. The third case shows that spontaneous remission can be observed in the course of rheumatoid meningitis. Rheumatoid meningitis, which is one of the rarest involvements in the course of RA, may present with headaches, focal neurological deficits, seizures, and altered consciousness. A meningeal biopsy is recommended when the differential diagnosis cannot be ruled out with imaging and laboratory findings. In the differential diagnosis Mucobacterium tuberculosis, syphilis, neuro-sarcoidosis, immunoglobulin G4-related disease, lymphoproliferative diseases, and systemic metastasis should be kept in mind. Aggressive RA management is recommended for treatment.
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Affiliation(s)
- Merve Aktan Suzgun
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nursena Erener
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gokce Hande Cavus
- Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ayse Ozdede
- Department of Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sabriye Guner
- Department of Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Serdal Ugurlu
- Department of Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nil Comunoglu
- Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sabahattin Saip
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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3
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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.
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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.
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4
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Galetta K, Bhattacharyya S. Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases. Semin Neurol 2021; 41:541-553. [PMID: 34619780 DOI: 10.1055/s-0041-1733790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.
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Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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5
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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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6
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Movement disorders in systemic autoimmune diseases: Clinical spectrum, ancillary investigations, pathophysiological considerations. Parkinsonism Relat Disord 2021; 88:116-128. [PMID: 34092506 DOI: 10.1016/j.parkreldis.2021.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/09/2021] [Accepted: 05/21/2021] [Indexed: 02/08/2023]
Abstract
With the advances in neuroimmunology especially due to the discovery of new neuronal antibodies, the recognition of treatable antibody-related movement disorders has recently received much attention. In contrast, the identification and characterisation of movement disorders associated with systemic autoimmune diseases remains a substantially unexplored area. Beyond the classic few associations such as chorea and antiphospholipid syndrome, or ataxia and coeliac disease, movement disorders have been reported in association with several systemic autoimmune diseases, however a clear image of clinical phenotypes, investigations, and treatment outcomes in these conditions has never been drawn. In this review, we analyse data from approximately 300 cases and summarise the epidemiological, clinical and diagnostic features of movement disorders associated with systemic autoimmune diseases, and the available knowledge about treatment and outcomes. We highlight that movement disorders in systemic autoimmune conditions are frequently the only or among a few presenting manifestations and are mostly treatable disorders responding to immunotherapy or dietary modifications. We point out the pertinent combination of clinical features and investigations which can suggest the underlying autoimmune nature of these movement disorders, and thus address the most appropriate treatment.
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7
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Del Bosque Granero I, Loarce-Martos J, Blázquez Cañamero MÁ, Buisan Catevilla FJ, Medina Díaz M, Bachiller-Corral FJ. Rheumatoid meningitis as a complication of long-standing rheumatoid arthritis: a case treated with rituximab. Mod Rheumatol Case Rep 2020; 5:200-205. [PMID: 33336629 DOI: 10.1080/24725625.2020.1860439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Rheumatoid meningitis is a rare complication of long-standing rheumatoid arthritis. We present the case of a 39-year-old Bolivian woman with a history of seropositive rheumatoid arthritis of 12 years of evolution without extra-articular manifestations that develops a severe headache with vomiting. The diagnosis of rheumatoid meningitis was performed based on clinical history, blood count and biochemistry results, cerebrospinal fluid analysis and cranial magnetic resonance imaging findings. High-dose intravenous glucocorticoids were started, followed by rituximab. After treatment, a significant clinical improvement was observed and repeat magnetic resonance imaging scan confirmed an improvement of the meningeal lesions.
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Affiliation(s)
| | - Jesús Loarce-Martos
- Department of Rheumatology, Ramón y Cajal University Hospital, Madrid, Spain
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8
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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.
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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
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9
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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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10
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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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11
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Okusa T, Shoji H, Oguri S, Nakano T. [Probable rheumatoid meningitis complicated by cryptococcal meningitis: A case report]. Rinsho Shinkeigaku 2020; 60:429-433. [PMID: 32435045 DOI: 10.5692/clinicalneurol.60.cn-001386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of rheumatoid meningitis complicated with cryptococcal meningitis in a 59-year-old female with rheumatoid arthritis. Migraine symptoms were followed by abnormal behavior, and the patient was admitted with fever and headache. On admission, her cerebrospinal fluid (CSF) contained 115 cells/μl, a protein content of 95 mg/dl, and a sugar level of 47 mg/dl; Her serum anti-cyclic citrullinated peptide (CCP) antibody value was high (174 U/ml), and a brain MRI showed enhanced gadolinium lesions in the cerebral/cerebellar pia mater and subarachnoid space, etc. Probable rheumatoid meningitis was clinically diagnosed, and a prednisolone (PSL) pulse was started. Several days later, a CSF culture test was positive for Cryptococcus neoformans, and the antigen titer was 128-fold. Liposomal-amphotericin B (L-AMB) was started for cryptococcal meningitis, combined with three PSL pulses for rheumatoid meningitis. After about 4 weeks, the number of CSF cells and anti-CCP antibodies decreased rapidly. At 2 months after the onset, the meningitis recurred. The MRI contrast lesions reappeared, and the CSF cells increased to 24/μl. Serum and CSF anti-CCP antibodies increased at the time of recurrence, but the cryptococcal antigen titer decreased. Thus, we concluded that the rheumatoid meningitis mainly involved the pathogenesis of both types of meningitis. The number of PSL pulses was limited to four. Post-perioral therapy was avoided. Methotrexate was continued for the rheumatoid meningitis, fluconazole was continued for the cryptococcal meningitis, and neither type of meningitis has recurred.
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Affiliation(s)
- Takafumi Okusa
- Department of Neurology, St. Mary's Hospital, Fukuoka.,Present address: Department of Obstetrics and Gynecology, Kurume University Hospital, Fukuoka
| | - Hiroshi Shoji
- Department of Neurology, St. Mary's Hospital, Fukuoka
| | - Shuichi Oguri
- Department of Radiology, St. Mary's Hospital, Fukuoka
| | - Teruaki Nakano
- Department of Rheumatology, St. Mary's Hospital, Fukuoka
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12
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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.
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13
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Im S, Kim MO, Kim SK, Jeong H, Kang H. Seropositive Rheumatoid Arthritis Presenting with Reversible Parkinsonism and Dysphagia. J Clin Neurol 2020; 16:336-337. [PMID: 32319255 PMCID: PMC7174115 DOI: 10.3988/jcn.2020.16.2.336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Seojun Im
- Department of Neurology, Gyeongsang National University Hospital, Jinju, Korea
| | - Min Ok Kim
- Department of Neurology, Gyeongsang National University Hospital, Jinju, Korea
| | - Soo Kyoung Kim
- Department of Neurology, Gyeongsang National University Hospital, Jinju, Korea.,Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Heejeong Jeong
- Department of Neurology, Changwon Gyeongsang National University Hospital, Changwon, Korea
| | - Heeyoung Kang
- Department of Neurology, Gyeongsang National University Hospital, Jinju, Korea.,Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, Korea.
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14
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Abdullah HMA, Omar M, Jbeli A, Fanciullo J. Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis. BMJ Case Rep 2019; 12:12/12/e231474. [PMID: 31822530 DOI: 10.1136/bcr-2019-231474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.
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Affiliation(s)
| | - Muhammad Omar
- Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
| | - Aiham Jbeli
- Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
| | - Joseph Fanciullo
- Rheumatology, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
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15
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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: 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: 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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Barba C, Alexopoulos H. Parkinsonism in autoimmune diseases. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 149:419-452. [DOI: 10.1016/bs.irn.2019.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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