[Multiple cerebral infarction associated with cerebral vasculitis in rheumatoid arthritis]

A 64-year-old woman was suffering from rheumatoid arthritis since the age of 57. At the age of 62, she manifested episcleritis of the eyes and rheumatoid nodules in the skin, and rheumatoid factor in the blood became high. These findings indicated the presence of systemic vasculitis, and she was treated with prednisolone. At the age of 64, she suddenly became delirious, and T2-weighted and diffusion-weighted MR images revealed fresh infarctions in bilateral temporal and parietal lobes of the cerebrum. MR angiography failed to show any narrowing or obstruction of large cerebral arteries. She had also high fever and arthralgia, and her blood showed elevated levels of white blood cells, erythrocyte sedimentation rate, C-reactive protein, IgG-rheumatoid factor and immune complex. Lumbar puncture revealed an elevated protein level in CSF. A daily dose of 60 mg prednisolone ameliorated these clinical and laboratory findings as well as her consciousness, disclosing disturbances in higher cortical functions including Wernicke aphasia, disorientation, and ideomotor, ideational, and constructional apraxia. Previous 13 reported cases of cerebral infarction complicating rheumatoid vasculitis were mostly described as showing multiple infarctions in cerebral hemisphere, disturbance of consciousness, elevated protein in CSF, and effectiveness of steroid therapy. The present case had these characteristics, and the cerebral vasculitis mediated by IgG-rheumatoid factor and immune complex was indicated as a probable cause of multiple cerebral infarctions.