Chronic meningitis with multiple cranial neuropathies: A rare initial presentation of Wegener's granulomatosis

Granulomatosis with polyangiitis presenting with unilateral facial nerve palsy and nasal septum perforation

Granulomatosis with polyangiitis (GPA) is a necrotising vasculitis of unknown cause that has several systemic manifestations. The disease is characterised by the classical triad involving acute inflammation of the upper and lower respiratory tracts with renal involvement. However, the disease pathology can involve the central nervous system. This case report presents a case of GPA with facial nerve palsy as the first manifestation of the disease, which has been rarely reported in the medical literature.

Seronegative granulomatosis with polyangiitis presenting with multiple cranial nerve palsies

Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis (WG), is a rare systemic disease characterized by necrotizing granulomas and vasculitis that usually presents in the respiratory tract and renal system. Here, we report a case of anti-neutrophil cytoplasmic antibody (ANCA)-negative GPA with diagnostic difficulties. Neurologic involvement in GPA is not uncommon, with up to 50% of patients manifesting with neurologic defects; however, it is usually a late event. This patient was a 50-year-old man whose first manifestation was multiple neurologic defects without respiratory or renal symptoms. Since multiple neurologic deficits were the first manifestation and there were no pulmonary or renal symptoms, our patient was treated for 1 year for suspected infectious or inflammatory diseases such as non-tuberculous mycobacterial infection or immunoglobulin G4 (IgG4)-related disease with brain involvement; however, his symptoms would wax and wane. Reanalysis of the laboratory findings including biopsies, finally revealed this case to be compatible with GPA. Here, we report a case of GPA, focusing on the diagnostic pitfalls.

Hypertrophic pachymeningitis

BACKGROUND

Hypertrophic pachymeningitis (HP) is a rare clinical entity characterized by diffuse or localized fibrous thickening of the dura mater. It is well known but rare especially in pediatric population disease of differing origins. The primary (idiopathic) form is diagnosed after excluding other possible etiologies. Similar results from magnetic resonance imaging (MRI) for patients with hypertrophic pachymeningitis and meningiomas may make the diagnosis confusing. Additionally, making a proper diagnosis without histological sampling can be difficult in some cases.

CASE DESCRIPTION

We present a case of an 18-year-old boy diagnosed with hypertrophic pachymeningitis in the area of the hypoglossal canal. The diagnosis was made after a 2-month history of hypoglossal nerve palsy and dysphagia preceded by a middle ear infection. The patient was treated surgically with suspicion of meningioma, but no evidence of a tumor was found during the operation. The postoperative period was uneventful. At the latest check-up, MRI revealed regression of all previously observed pathological changes.