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Case Report ARTICLE Provisionally accepted The full-text will be published soon. Notify me

Front. Neurol. | doi: 10.3389/fneur.2019.00163

Rheumatoid Meningitis Presenting with Acute Parkinsonism and Protracted Non-Convulsive Seizures: An Unusual Case Presentation and Review of Treatment Strategies

 David Pellerin1, Michael Wodkowski2, Marie-Christine Guiot3, Hisham AlDhukair1, 4,  Andrea Blotsky5, Jason Karamchandani3, Evelyne Vinet2, Anne-Louise Lafontaine1 and  Stuart Lubarsky1, 6*
  • 1Department of Neurology and Neurosurgery, McGill University, Canada
  • 2Division of Rheumatology, Department of Medicine, McGill University, Canada
  • 3Department of Pathology, McGill University, Canada
  • 4Department of Neurology, King Fahad Medical City, Saudi Arabia
  • 5Division of General Internal Medicine, Department of Medicine, McGill University, Canada
  • 6Centre for Medical Education, Faculty of Medicine, McGill University, Canada

Rheumatoid meningitis is a rare complication of rheumatoid arthritis. It is associated with substantial morbidity and mortality. The condition may present in a variety of ways and is therefore diagnostically challenging. Uncertainty still exists regarding the optimal treatment strategy. Herein, we describe the case of a 74-year-old man with a history of well-controlled seropositive rheumatoid arthritis on low-dose prednisone, hydroxychloroquine and methotrexate. The patient presented with a several-month history of multiple prolonged episodes of expressive aphasia, right hemiparesis and encephalopathy. Although no epileptiform activity was recorded on repeated electroencephalography, the symptoms fully resolved following treatment with antiepileptic drugs. He subsequently developed acute asymmetrical parkinsonism of the right hemibody. Magnetic resonance imaging revealed subtle enhancement of the leptomeninges over the left frontoparietal convexity. Cerebrospinal fluid analysis revealed a normal cell count and elevated proteins. Histopathologic analysis of a meningeal biopsy revealed nodular rheumatoid meningitis. The patient was treated with corticosteroids and cyclophosphamide, following which he incompletely recovered. This is the first description of rheumatoid meningitis manifesting with acute parkinsonism and protracted non-convulsive seizures. A summary of cases reported since 2005, including data on pathology, therapy and outcomes, along with a discussion on the efficacy of different treatment strategies are provided.

Keywords: Rheumatoid arthritis, Rheumatoid meningitis, Vasculitis < rheumatic diseases, Parkinsonism (extrapyramidal signs), seizure, Immunosuppressant, corticosteroids

Received: 24 Nov 2018; Accepted: 07 Feb 2019.

Edited by:

Fernando Testai, University of Illinois at Chicago, United States

Reviewed by:

Benjamin A. Emanuel, Keck School of Medicine of USC, University of Southern California, United States
Rick Gill, Loyola University Chicago, United States  

Copyright: © 2019 Pellerin, Wodkowski, Guiot, AlDhukair, Blotsky, Karamchandani, Vinet, Lafontaine and Lubarsky. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Stuart Lubarsky, Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada, stuart.lubarsky@mcgill.ca