McKenna Mary Clare, Vaughan David, Bermingham Niamh, Cronin Simon
Department of Neurology, Cork University Hospital, Cork, Ireland.
Department of Neuropathology, Cork University Hospital, Cork, Ireland.
BMJ Case Rep. 2019 Jan 10;12(1):bcr-2018-226649. doi: 10.1136/bcr-2018-226649.
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.
类风湿性脑膜炎（RM）是类风湿关节炎（RA）一种罕见的关节外表现。一名59岁男性，有10天的右侧额部头痛病史和7天的亚急性左侧肢体无力病史。他既往无RA病史。他发热（38.2°C）。左侧踝关节背屈和跖屈肌力分级为4+/5。他出现局灶性发作性癫痫。尽管静脉使用了抗病毒药物和抗菌药物，他仍间歇性发热，症状改善甚微。血清学检查显示类风湿因子升高至88.2 IU/mL，抗环瓜氨酸肽（anti-CCP）IgG>340 AU/mL。初始脑脊液（CSF）主要为淋巴细胞（96%），蛋白升高至672 mg/L，葡萄糖正常为3.4 mmol/L。复查脑脊液显示葡萄糖新降至2.6 mmol/L。广泛的脑脊液微生物学检查均为阴性。脑脊液细胞学检查证实为反应性淋巴细胞。脑部MRI显示右侧额顶叶软脑膜强化。脑和软脑膜活检显示软脑膜有明显的混合性炎性浸润，无肉芽肿形成。抗CCP IgG升高、侵蚀性关节病、脑脊液淋巴细胞增多、不对称性软脑膜强化及活检结果相结合，确诊为RM。
