Pearls & Oy-sters: Rheumatoid meningitis occurring during treatment with etanercept

Rheumatoid meningitis is a rare condition that can manifest as cognitive impairment, focal neurologic signs, cranial nerve dysfunction, seizures, and headache.Suspicious neuroimaging findings include fluid-attenuated inversion recovery (FLAIR) hyperintensities along the meninges and subarachnoid space as well as enhancement of meninges on gadolinium-enhanced T1-weighted images.Meningeal biopsy reveals infiltration of mononuclear cells, vasculitis, and rheumatoid nodules.Treatment includes corticosteroids alone or in combination with azathioprine, cyclophosphamide, methotrexate, or rituximab. Oy-stersRheumatoid meningitis can occur despite longstanding treatment with anti-tumor necrosis factor -(TNF)-α agents.Differential diagnosis includes infectious meningitis, vasculitis, neurosarcoidosis, neurosyphilis, leptomeningeal carcinomatosis, and drug-induced meningitis.Nonspecific lumbar puncture findings and asymmetric involvement on MRI should not lead one away from the diagnosis, since these are common findings in rheumatoid meningitis. Case descriptionA 77-year-old woman with a long-standing history of rheumatoid arthritis (RA) being treated with etanercept and leflunomide for 9 years presented with multiple episodes of speaking difficulty and paresthesia in her left limbs.These episodes started 1 month prior to admission.Initially, symptoms occurred once or twice a week, then gradually increased in frequency to become daily.Each episode lasted approximately 10-20 minutes.On admission, the patient was noted to have temporal disorientation, intermittent dysarthria, and left hemiparesis predominantly affecting the leg (with a Medical Research Council score of 4/5 in the lower limb and 4+/5 in the upper limb).RA symptoms were well-controlled with treatment.The patient reported no articular pain or signs of active inflammation.