Gondal Muhammad Umer Riaz, Graves Josette, Khan Haider, Baig Mohammad, Khan Toqeer, Khalid Fatima, Pagolu Pavani
Department of Internal Medicine, Tower Health, Reading Hospital, West Reading, USA.
Department of Internal Medicine, Drexel University, West Reading, USA.
Eur J Case Rep Intern Med. 2024 Nov 11;11(12):004964. doi: 10.12890/2024_004964. eCollection 2024.
Rheumatoid pachymeningitis and optic neuritis are rare complications of rheumatoid arthritis (RA) and are a diagnosis of exclusion.
A 75-year-old male with a history of seronegative RA presented to the emergency department with left eye pain and blurry vision lasting two days. He had been diagnosed with seronegative RA around nine months previously. His blood pressure was elevated at 204/75 mmHg upon arrival. Physical examination revealed left conjunctival injection, mild ptosis, painful extraocular movements and tenderness over the orbit and sinuses. Initial treatments included painkillers and intravenous labetalol, which alleviated his symptoms and decreased his blood pressure. Laboratory tests showed a C-reactive protein of 2.5 mg/dl and an erythrocyte sedimentation rate of 32 mm/h, with other blood work unremarkable. A computed tomography (CT) angiogram of the head and neck showed no high-grade stenosis. Given his RA history, initial concerns included scleritis. A magnetic resonance imaging (MRI) of the brain and orbit revealed inflammation around the left optic nerve, and pachymeningitis at the left cerebral convexity and interhemispheric fissure, suggesting hypertrophic pachymeningitis. An ophthalmologic examination was unremarkable. Treatment was adjusted to include pulse doses of intravenous methylprednisolone for optic neuritis, resulting in significant pain relief. Though inadequate for complete testing, a lumbar puncture indicated an inflammatory disorder with elevated glucose (199 mg/dl), protein (109 mg/dl), and unremarkable WBC/RBC and Gram staining. Cytology and culture were unremarkable. The most likely diagnosis at this point was rheumatological meningitis and rheumatological optic neuritis. The patient improved markedly with high-dose steroids over four days and was discharged on prednisone.
In cases of optic neuritis and pachymeningitis, RA should remain on the differential in patients with or without a prior diagnosis.
Rheumatoid arthritis (RA) is a systemic disease but can rarely cause neurological involvement.Pachymeningitis is an inflammation of the dura mater, rarely caused by RA.Optic neuritis can also rarely be caused by RA and responds to steroids.
类风湿性硬脑膜炎和视神经炎是类风湿关节炎（RA）的罕见并发症，属于排除性诊断。
一名75岁男性，有血清阴性RA病史，因左眼疼痛和视力模糊持续两天就诊于急诊科。他大约在九个月前被诊断为血清阴性RA。入院时血压升高，为204/75 mmHg。体格检查发现左眼结膜充血、轻度上睑下垂、眼球运动疼痛以及眼眶和鼻窦压痛。初始治疗包括止痛药和静脉注射拉贝洛尔，这缓解了他的症状并降低了血压。实验室检查显示C反应蛋白为2.5 mg/dl，红细胞沉降率为32 mm/h，其他血液检查无异常。头颈部计算机断层扫描（CT）血管造影显示无高级别狭窄。鉴于他的RA病史，最初考虑为巩膜炎。脑部和眼眶的磁共振成像（MRI）显示左侧视神经周围炎症，左侧大脑凸面和大脑镰旁有硬脑膜炎，提示肥厚性硬脑膜炎。眼科检查无异常。治疗调整为包括静脉注射甲基强的松龙脉冲剂量治疗视神经炎，疼痛明显缓解。虽然腰椎穿刺不足以进行全面检查，但显示为炎症性疾病，葡萄糖（199 mg/dl）、蛋白质（109 mg/dl）升高，白细胞/红细胞及革兰氏染色无异常。细胞学和培养无异常。此时最可能的诊断是风湿性脑膜炎和风湿性视神经炎。患者在四天内使用大剂量类固醇后明显好转，出院时服用泼尼松。
在视神经炎和硬脑膜炎病例中，无论患者之前是否有诊断，RA都应列入鉴别诊断。
类风湿关节炎（RA）是一种全身性疾病，但很少引起神经系统受累。硬脑膜炎是硬脑膜的炎症，很少由RA引起。视神经炎也很少由RA引起，对类固醇有反应。
