Lint: rheumatoid-meningitis

"Rheumatoid meningitis is considered a very rare manifestation of rheumatoid arthritis, although the exact incidence is not known. There is a slight female predilection among published case reports and series ¹. Up to one-third of patients presenting with rheumatoid meningitis do not have a known diagnosis of rheumatoid arthritis prior to presentation ^1,2."

"Diagnosis of rheumatoid meningitis is made if there is a typical clinicoradiological phenotype, cerebrospinal fluid (CSF) lymphocytic pleocytosis, and positive serum serology for rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide (anti-CCP or ACPA) ⁴. In cases of diagnostic uncertainty, a meningeal biopsy should be considered ⁴."

"Cerebrospinal fluid (CSF) analysis typically reveals a lymphocytic pleocytosis, although normal cell counts have rarely been described, and a raised protein ¹. CSF-restricted oligoclonal bands may be present ⁶. An elevated CSF anti-cyclic citrullinated peptide antibody index may also be suggestive ⁶. In serum, the vast majority of patients are positive for rheumatoid factor ^1-3. When tested, serum anti-cyclic citrullinated peptide (anti-CCP or ACPA) is also usually positive ^1-3."

"Treatment is with immunosuppression ^1,7. Initially, this is generally with intravenous methylprednisolone followed by oral corticosteroid taper ^1,7. A steroid-sparing immunosuppressive (e.g. methotrexate, cyclophosphamide, rituximab) is often then used as maintenance therapy ^1,7. Notably, TNF-alpha inhibitors may not be as effective in rheumatoid meningitis as they are for articular manifestations of rheumatoid arthritis ^1,7."