BMJ Case Reports 2018; doi:10.1136/bcr-2017-222587
  • Rare disease

Rheumatoid disease: an unusual cause of relapsing meningoencephalitis

  1. Alberto Cifelli1
  1. 1Department of Neurology, Queen’s Hospital, Romford, UK
  2. 2Department of Rheumatology, Queen’s Hospital, Romford, UK
  3. 3Department of Pathology, Queen’s Hospital, Romford, UK
  1. Correspondence to Dr Sian K Alexander, siankathalexander{at}
  • Accepted 18 December 2017
  • Published 12 January 2018


A 73-year-old man presented with three episodes of dysphasia and disinhibited behaviour, a single seizure and transient ischaemic attack-like events characterised by right arm and/or leg weakness. These episodes were separated by month-long asymptomatic intervals. Medical history included rheumatoid arthritis, which was clinically quiescent on leflunomide.

Repeated cerebrospinal fluid examination showed a persistent lymphocytosis with mildly reduced glucose and elevated protein; oligoclonal bands and viral PCR were negative. MRI of the brain was initially normal, but 7 months after initial presentation revealed meningeal enhancement with bifrontal cortical hyperintensities on T2/fluid-attenuated inversion recovery. Brain biopsy demonstrated necrotising granulomatous meningitis with mixed T cell and B cell infiltrates and without evidence of vasculitis or infection. Serum anticyclic citrullinated peptide antibodies were strongly positive.

The diagnosis of rheumatoid meningoencephalitis was made on the basis of brain biopsy findings and serological evidence of active rheumatoid disease. Steroids and rituximab therapy were started leading to clinical stabilisation.


  • Contributors SKA drafted the paper. UP contributed to the neuropathology information. MDC, UP and AC revised the paper. All authors contributed to the clinical care of the patient.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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