Rheumatoid disease: an unusual cause of relapsing meningoencephalitis

Area of Science:

• Neurology
• Immunology
• Rheumatology

Background:

• Rheumatoid arthritis (RA) is a chronic autoimmune disease primarily affecting joints.
• Neurological complications of RA are uncommon but can be severe.
• Rheumatoid meningoencephalitis (RME) is a rare manifestation involving central nervous system inflammation.

Observation:

• A 73-year-old male with quiescent RA presented with episodic neurological symptoms including dysphasia, disinhibited behavior, seizures, and transient ischemic attack-like events.
• Cerebrospinal fluid analysis revealed persistent lymphocytosis, mildly reduced glucose, and elevated protein.
• Brain MRI showed meningeal enhancement and bifrontal cortical hyperintensities, with biopsy confirming necrotizing granulomatous meningitis.

Findings:

• The patient had strongly positive anti-cyclic citrullinated peptide (anti-CCP) antibodies.
• Brain biopsy revealed necrotizing granulomatous meningitis with mixed T and B cell infiltrates, excluding vasculitis or infection.
• Diagnosis of RME was established based on clinical presentation, biopsy, and serological markers of active RA.

Implications:

• This case highlights the importance of considering RME in RA patients with unexplained neurological symptoms.
• Prompt diagnosis and initiation of immunosuppressive therapy, including steroids and rituximab, can lead to clinical stabilization.
• Further research into the pathogenesis and optimal management of RME is warranted.