Rheumatoid meningitis: a rare neurological complication of rheumatoid arthritis

Siyuan Fan; Jiuliang Zhao; Bo Hou; Mange Liu; Jingwen Niu; Yan Zhou; Chenhui Mao; Haitao Ren; Feng Feng; Mengtao Li; Xiaofeng Zeng; Yicheng Zhu; Hongzhi Guan

doi:10.3389/fimmu.2023.1065650

Rheumatoid meningitis: a rare neurological complication of rheumatoid arthritis

Front Immunol. 2023 Jun 7:14:1065650. doi: 10.3389/fimmu.2023.1065650. eCollection 2023.

Authors

Siyuan Fan¹, Jiuliang Zhao^{2

3

4

5}, Bo Hou⁶, Mange Liu¹, Jingwen Niu¹, Yan Zhou¹, Chenhui Mao¹, Haitao Ren¹, Feng Feng⁶, Mengtao Li^{2

3

4

5}, Xiaofeng Zeng^{2

3

4

5}, Yicheng Zhu¹, Hongzhi Guan¹

Affiliations

¹ Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
² Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
³ National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China.
⁴ State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China.
⁵ Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
⁶ Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

Abstract

Objective: To describe the clinical and neuroimaging characteristics of rheumatoid meningitis (RM) in Chinese patients.

Methods: The patients admitted to our hospital with the diagnosis of RM in the past 8 years were retrospectively analyzed.

Results: Six patients with RM were identified among 933 patients admitted with rheumatoid arthritis (RA). The symptoms of meningitis occurred after onset of arthritis in five patients and before onset in one. Headache (n=6), hyperacute focal neurological deficits (n=4) and seizures (n=3) were the most prevalent symptoms. The nadir modified Rankin Scale score was ≥3 in five patients. Rheumatoid factor was elevated in all patients, and interleukin-6 levels in cerebrospinal fluid were dramatically elevated in three of four tested patients. Magnetic resonance imaging of the brain revealed that the meninges were affected in all patients and the cerebral parenchyma was affected in one patient. The lesions were generally located in the frontoparietal region and showed restricted diffusion along the adjacent subarachnoid space. RM occurred during disease-modifying therapy in four patients. In the acute episode, three patients improved on tocilizumab and the other three improved on pulse corticosteroids. For maintenance therapy, two patients received combined therapy of tocilizumab and other immunosuppressive agents, one received adalimumab and methotrexate, and two received low-dose oral corticosteroids with an immunosuppressive agent. Five patients had a good outcome, and one died of Pneumocystis jirovecii pneumonia after stabilization of his neurologic conditions. No relapse of RM occurred on immunotherapy during follow-up.

Conclusions: Chinese patients with RM share some remarkable clinical and neuroimaging features and respond well to appropriate immunotherapy. Tocilizumab could be a treatment option for this severe complication of RA.

Keywords: immunotherapy; neuroimage; rheumatoid arthritis; rheumatoid meningitis; tocilizumab (TCZ).

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adrenal Cortex Hormones / therapeutic use
Arthritis, Rheumatoid* / drug therapy
Humans
Meningitis* / etiology
Methotrexate / therapeutic use
Retrospective Studies

Substances

Methotrexate
Adrenal Cortex Hormones

Grants and funding

This study was supported by the CAMS Innovation Fund for Medical Sciences (CIFMS: 2021-I2M-C&T-A-002) and the National High Level Hospital Clinical Research Funding (2022-PUMCH-B-120).