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CASE REPORT
Rheumatoid arthritis presenting as rheumatoid meningitis
  1. Mary Clare McKenna1,
  2. David Vaughan1,
  3. Niamh Bermingham2 and
  4. Simon Cronin1,3
  1. 1 Department of Neurology, Cork University Hospital, Cork, Ireland
  2. 2 Department of Neuropathology, Cork University Hospital, Cork, Ireland
  3. 3 Department of Clinical Neuroscience, College of Medicine and Health, University College Cork, Cork, Ireland
  1. Correspondence to Dr Simon Cronin, simon.cronin{at}hse.ie

Abstract

Rheumatoid meningitis (RM) is a rare extra-articular manifestation of rheumatoid arthritis (RA). A 59-year-old man presented with a 10-day history of right-sided frontal headache and a 7-day history of subacute left-sided weakness. He had no history of RA. He was febrile (38.2°C). Left ankle dorsiflexion and plantarflexion were graded at 4+/5. He developed focal onset motor seizures. He was intermittently febrile with minimal improvement despite intravenous antivirals and antimicrobials. Serology revealed elevated rheumatoid factor 88.2 IU/mL and anti-cyclic citrullinated peptide (anti-CCP) IgG >340 AU/mL. Initial cerebrospinal fluid (CSF) was predominantly lymphocytic 96%, with elevated protein 672 mg/L and normal glucose 3.4 mmol/L. Interval CSF revealed newly low glucose 2.6 mmol/L. Extensive CSF microbiology tests were negative. CSF cytology confirmed reactive lymphocytes. MRI brain revealed right frontoparietal leptomeningeal enhancement. Brain and leptomeningeal biopsy demonstrated florid leptomeningeal mixed inflammatory infiltrate without granulomas. The combination of elevated anti-CCP IgG, erosive arthropathy, CSF lymphocytosis, asymmetrical leptomeningeal enhancement and biopsy findings confirmed RM.

  • rheumatoid arthritis
  • meningitis
  • headache (including migraines)

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Footnotes

  • Contributors All authors reviewed and edited the manuscript. MCMcK wrote the manuscript and was involved in case management. DV was involved in case management. NB reviewed the neuropathology. SC led clinical management of case. He also led conception, supervision and editing of manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

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

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