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Neurological rarities
Rheumatoid leptomeningitis presenting with an acute neuropsychiatric disorder
  1. Michal Lubomski1,2,
  2. Joanne Sy3,
  3. Michael Buckland3,4,
  4. Andie S Lee5,
  5. Bethan Richards6,
  6. Elizabeth Thompson7,
  7. Michael Fulham8,
  8. Nora Breen9,
  9. Kirsty Morris10,
  10. G Michael Halmagyi1
  1. 1 Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  2. 2 School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
  3. 3 Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  4. 4 Discipline of Pathology, University of Sydney, Sydney, New South Wales, Australia
  5. 5 Department of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  6. 6 Department of Rheumatology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  7. 7 Radiology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  8. 8 Department of Molecular Imaging and Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  9. 9 Neuropsychology Unit, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  10. 10 Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  1. Correspondence to Dr Michal Lubomski, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia; michal.lubomski{at}nd.edu.au

Abstract

Leptomeningitis is a rare central nervous system manifestation of rheumatoid arthritis, generally in patients with established chronic rheumatoid disease. We report a 41-year-old man without previous rheumatoid arthritis or psychiatric disorder who presented with an acute neuropsychiatric disturbance and polyarthralgia. His MR scan of brain showed asymmetric bifrontal leptomeningitis, confirmed on (18F)-fluoro-D-glucose-positron emission tomography. Other investigations showed highly positive serum and cerebrospinal fluid anti-cyclic citrullinated peptide. A leptomeningeal biopsy showed necrotising leptomeningeal inflammation with ill-defined granulomas and lymphoplasmacytic infiltrate without organisms. Prolonged high-dose corticosteroids and then rituximab resulted in recovery. Chronic leptomeningitis can present with an acute neuropsychiatric disorder. We highlight that early rheumatoid disease can, rarely, cause a chronic leptomeningitis, reversible with immunotherapy.

  • rheumatoid meningitis
  • leptomeningitis
  • pachymeningits
  • neuropsychiatric disturbance
  • rheumatoid arthritis

http://dx.doi.org/10.1136/practneurol-2018-001978

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    Footnotes

    • Contributors ML was involved in the inpatient management of the patient, study concept, literature review and writing of the manuscript. JS was involved in the reporting of the histopathology, study concept and writing of the manuscript. MB was involved in the reporting of the histopathology, study concept and writing of the manuscript. ASL was involved in the inpatient management of the patient and writing of the manuscript. BR was involved in the inpatient management of the patient and writing of the manuscript. ET was involved in the reporting of MRI imaging and writing of the manuscript. MF was involved in the reporting of PET imaging and writing of the manuscript. NB was involved in the inpatient management of the patient and writing of the manuscript. KM involved in the inpatient management of the patient and writing of the manuscript. GMH was involved in the inpatient management of the patient, study concept, writing of the manuscript and research supervision.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed by Desmond Kidd, London, UK.

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