Case Report: Rheumatoid meningitis with positive NMDAR antibody: A case treated with intravenous immunoglobulin
Honglian Zhang1, Yuehong Wan1, Zhujun Mei1
1Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China.
Abstract:
As a rare complication of rheumatoid arthritis (RA) in the central nervous system (CNS), rheumatoid meningitis (RM) mainly affects the meninges and has various clinical symptoms. The diagnostic and treatment approaches currently used are not practical. RM cases with positive NMDAR antibodies (Abs) have never been reported. In the present study, a 66-year-old man with a 1-year history of RA presented recurrent left lower limb weakness during activities for 1 month. The results showed that rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) were positive in the serum, and NMDAR Abs were present in cerebrospinal fluid (CSF). Hyperintensity was observed in the leptomeninges of the right frontal and parietal lobes, and subtle hyperintensity was observed in the left frontal and parietal lobes, as indicated by brain MRI. A meningeal biopsy revealed non-specific inflammation with the absence of rheumatoid nodules. The patient was given IVIg on day 7 after admission. The clinical symptoms were relieved, the lesions were alleviated, and abnormal biochemical indicators were gradually recovered 1 week after initiation of the treatment, while NMDAR Abs were present in CSF even after treatment. After 5 months of follow-up, the patient's serum and CSF ACPA and IL-6 levels were still high. The findings showed that brain MRI was adequate for the diagnosis of RM. ACPA and IL-6 might be the specific biomarkers for disease activity in RM. IVIg was effective as induction therapy for RM. Further studies should explore whether the presence of NMDAR Abs is associated with RM.
Insights
This study reports a rare case of rheumatoid meningitis (RM) in a rheumatoid arthritis (RA) patient with positive N-methyl-D-aspartate receptor (NMDAR) antibodies. Intravenous immunoglobulin (IVIg) effectively treated the RM symptoms and inflammation.
Area of Science:
- Neurology
- Rheumatology
- Immunology
Background:
- Rheumatoid meningitis (RM) is a rare central nervous system complication of rheumatoid arthritis (RA).
- Current diagnostic and treatment strategies for RM are often impractical.
- RM cases with positive N-methyl-D-aspartate receptor (NMDAR) antibodies have not been previously documented.
Observation:
- A 66-year-old male RA patient presented with recurrent lower limb weakness.
- Cerebrospinal fluid (CSF) analysis revealed positive NMDAR antibodies, while serum tests showed positive rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA).
- Brain MRI indicated leptomeningeal hyperintensity, and a meningeal biopsy showed non-specific inflammation.
Findings:
- The patient responded well to intravenous immunoglobulin (IVIg) therapy, with symptom relief and lesion alleviation within one week.
- Despite treatment, NMDAR antibodies remained detectable in CSF.
- Elevated serum and CSF levels of ACPA and IL-6 persisted post-treatment, suggesting their potential role as biomarkers for RM disease activity.
Implications:
- Brain MRI is a valuable tool for diagnosing RM.
- ACPA and IL-6 may serve as specific biomarkers for monitoring RM disease activity.
- IVIg shows promise as an effective induction therapy for RM.
- Further research is warranted to investigate the potential association between NMDAR antibodies and RM.
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