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Case Reports
. 2017:2017:7638539.
doi: 10.1155/2017/7638539. Epub 2017 Feb 13.

Rheumatoid Meningitis Occurring during Etanercept Treatment

Koji Tsuzaki  1 , Takashi Nakamura  2 , Hiroyuki Okumura  3 , Naoko Tachibana  1 , Toshiaki Hamano  1
Affiliations
Case Reports

Rheumatoid Meningitis Occurring during Etanercept Treatment

Koji Tsuzaki et al. Case Rep Neurol Med. 2017.

Abstract

We report a 65-year-old man who had repetitive seizures 6 months after receiving etanercept, methotrexate, and prednisolone for rheumatoid arthritis. Mononuclear cells were mildly increased in the cerebrospinal fluid (CSF). Brain magnetic resonance imaging (MRI) showed high intensity along sulci of the frontal and parietal lobes. Brain biopsy revealed lymphocyte and plasma cell infiltration in the meninges, confirming the diagnosis of rheumatoid meningitis. After steroid pulse therapy, seizures resolved and clinical findings improved. When etanercept was replaced by tocilizumab, rheumatoid meningitis did not recur. Although TNF-α inhibitors can control joint symptoms of rheumatoid arthritis, they may induce rheumatoid meningitis.

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Conflict of interest statement

The authors declare that there is no conflict of interests regarding the publication of this paper.

Figures

Figure 1
Figure 1
Clinical course. After the treatment with intravenous methylprednisolone, cell counts and proteins of CSF decreased, and seizures disappeared. MTX: methotrexate, ETN: etanercept, PSL: prednisolone, CBZ: carbamazepine, VPA: sodium valproate, LEV: levetiracetam, ZNS: zonisamide, and mPSL: methylprednisolone.
Figure 2
Figure 2
Brain MRI findings on the 4th admission. (a) Axial T2 fluid-attenuated inversion recovery (FLAIR) image (1.5 T; TR 10000 ms, TE 108 ms). (b) Diffusion-weighted image (DWI) (1.5 T; TR 5000 ms, TE 75 ms). (c) T1-weighted image (T1WI) enhanced by gadolinium (1.5 T; TR 7.50 ms, TE 2.82 ms). MRI shows extensive thick linear hyperintensity of the leptomeninges in bilateral frontal lobe and the left parietal lobe on T2 FLAIR and DWI (red arrows). T1WI after gadolinium administration shows enhancement of the leptomeninges (red arrowhead).
Figure 3
Figure 3
Brain biopsy. Microscopic view of biopsied specimen showed leptomeningitis with plasma cells and lymphocytes infiltration. Haematoxylin and eosin stain, magnification of (a) 100x and (b) 400x.
Figure 4
Figure 4
Brain MRI finding 2 years after treatment. T2 FLAIR image (1.5 T; TR 10000 ms, TE 108 ms). MRI performed 2 years after treatment no longer shows linear hyperintensity of the leptomeninges.
See this image and copyright information in PMC

References

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