Abstract
Introduction We report a rare presentation of recurrent stroke like symptoms secondary to rheumatoid meningitis in a patient with well controlled rheumatoid arthritis.
Case A 65-year-old-gentleman with a background of rheumatoid arthritis developed sudden onset of expressive aphasia and right-sided weakness. Over the next two weeks, he had recurrent such stereotyped episodes . Pyrexia and night sweats were also noted during admission. Magnetic resonance imaging (MRI) of brain showed multifocal leptomeningeal enhancement which progressed on short interval serial imaging. Cerebrospinal fluid (CSF) analysis showed elevated protein, low glucose and elevated white blood cells which were predominately mononuclear. Electroencephalogram captured one of the episodes wherein there was corresponding pleomorphic delta slowing of the left temporal leads, suggestive of a possible epileptiform abnormality. A diagnosis of likely rheumatoid meningitis was made after exclusion of infective and alternative causes on extensive diagnostic testing including blood, CSF, radiological and nuclear medicine investigations. Treatment with pulsed intravenous methylprednisolone followed by oral prednisolone taper resulted in remission of symptoms and resolution of MRI findings. He remains well a year on.
Conclusion Rheumatoid meningitis is rarely described but important differential to consider in a patient presenting with recurrent stroke-like focal neurological symptoms associated with aseptic meningitis with a known rheumatoid arthritis. It can be seen in patients whose peripheral manifestations of rheumatoid arthritis are well controlled on disease modifying therapy, as in our patient. Early treatment with high dose corticosteroids can be helpful after exclusion of infection and malignant causes.
