Rheumatoid Meningoencephalitis: A Feared Condition in the Era of TNF Blockers

Abstract

Central nervous system (CNS) involvement in rheumatoid arthritis (RA) is uncommon, and most of the times, it is secondary to vasculitic processes or extra-articular rheumatoid nodules. Meningeal involvement is extremely rare. In the literature, there are a few case reports, series, and retrospective studies which have demonstrated the association of rheumatoid (aseptic) meningoencephalitis after starting tumor necrosis factor (TNF) inhibitors. We present a case of rheumatoid meningoencephalitis (RME) in a 52-year-old male with a history of RA on adalimumab who presented with headaches associated with motor and sensory deficits, all of which resolved after this diagnosis was achieved and received appropriate therapy with high-dose glucocorticoids. We also present an update with high yield points summarizing clinical features, diagnostic workup, and management of RME. Finally, we post a literature review of relevant CNS rheumatoid disease in patients with and without exposure to TNF inhibitors.

Figure 1

(a) Initial CT scan showing increased diffuse enhancement of right cerebrum as well as ill-defined hypodensity in the posterior right frontal lobe (circle). Slight mass effect is shown upon right lateral ventricle with edema (arrow). (b) MRI brain with gadolinium showing parenchymal and leptomeningeal enhancement over the right frontal and temporal lobes with associated T2/FLAIR signal involving right frontal lobe cortex (arrows), finding suggestive of meningoencephalitis.

Figure 2

Biopsy report.

Figure 3

(a) Chronic leptomeningitis with giant cells. (b) Chronic leptomeningitis is demonstrated again; in this cut, parenchymal perivascular lymphocytic infiltrates are appreciated.