Rheumatoid leptomeningitis: a case report and literature review / 北京大学学报(医学版)

ABSTRACT

To report the clinical, radiological and neuropathological findings of a patient with rheuma-toid meningitis. The patient was a 71-year-old Chinese man with a two-year history of rheumatoid arthritisand no other significant medical history, who presented to our hospital recurrent weakness of his left ex-tremities, dysarthria and a continuous bilateral hand tremor. Cerebrospinal fluid (CSF) and serumexam-inations were normal apart from a mildly raised serum perinuclear antineutrophil cytoplasmic autoantibody(p-ANCA). Brain magnetic resonance imaging (MRI) showed leptomeningeal enhancementin both fron-tal and parietal lobes, in addition to several old white matter infarcts. Meningeal biopsy showed numerousinfiltrating macrophages and lymphocytes within the leptomeninges. The patient responded clinically andradiologically to corticosteroid and cyclophosphamide therapy. The patient subsequently developed herpeszoster over his left chest as a complication of his immunosuppressive treatment. His cyclophosphamidewas ceased and intravenous immunoglobulin (IVIG) therapy was commenced, with good clinical responseto both the herpes zoster and meningitis. According to the result of the biopsy, aseptic meningitis wasconsidered the MRI results and the patient’s clinical history were given, and a diagnosis of rheumatoidmeningitis was made. The patientwas p-ANCApositive. Although there was no evidence for cerebral vas-culitis on biopsy, it remains a possibility that the patient’s recurrent minor cerebral infarcts visible onMRI were vasculitic in nature.