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September 2015

Rheumatoid Meningitis Presenting With Multiple Strokelike Episodes

Author Affiliations
  • 1Department of Neurology, University of Connecticut, Hartford
  • 2Hartford Hospital, Hartford, Connecticut
JAMA Neurol. 2015;72(9):1073-1076. doi:10.1001/jamaneurol.2015.1105

Central nervous system involvement, in the form of meningitis or vasculitis with or without meningeal nodules, is a rare complication of rheumatoid arthritis (RA).1 It can be independent of disease activity or duration.2 Exact pathology remains unclear but it is associated with infiltration of mononuclear cells around small vessels in the leptomeninges. Rheumatoid meningitis can present as altered mental status (most common), cranial neuropathies, hemiparesis/paraparesis, seizure, and headache. To our knowledge, strokelike symptoms as the initial presentation has rarely been reported.1,2 Here, we report a case of rheumatoid meningitis presenting with multiple strokelike episodes.

A woman in her late 50s with RA for many years, well controlled with methotrexate and sulfasalazine, initially developed mild aphasia and confusion lasting for several hours. A month later, she developed sudden-onset right leg weakness, which resolved within 2 days. Two months later, she presented to our hospital with mild headache and right facial droop. She had controlled hypertension and hyperlipidemia. She had never received any other immunomodulators. Her neurological examination was significant for some paraphasic errors, word-finding difficulty, mild right nasolabial flattening, and bilateral upgoing plantars without any motor or sensory deficits.