Rheumatoid Meningitis: Clinical, Radiological, and Therapeutic Insights from a Complex Case Report
Dante Oropeza Canto1, Yadira Tiburcio-Núñez2, Guadalupe Cecilia Aguilar-Domínguez3, Daniel Arizpe-Bravo4, Ana Berta Arizpe-Bravo5, David Blumenkron-Marroquín2, Maricruz Velázquez-Vaquero6, Eduardo Peña-Andrade6, Luis Angel Haro-Santillan6, Armando Romero-Pérez7, Carlos Enrique Chávez-Donis8
1Electrodiagnostico Cerebral De Puebla S.C., 2Neurology, 3Rheumatology, 4Critical medicine, 5Infectology, 6Clinical neurophysiology, 7Neurosurgery, 8Psychiatry, Hospital Angeles
Background:
Rheumatoid Meningitis (RM) is rare and severe neurologic complication of rheumatoid arthritis (RA). Approximately 165 cases have been report worldwide (1). Neurologic symptoms include headache, seizures, focal neurologic deficits, altered mental status and cranial nerve syndromes. Symptoms of meningitis typically occur after onset arthritis, although not all patients present RA symptoms before RM (2-3). RM follows sex distribution seen in RA, being more common in females than males (3). Frequently, involves pachymeningitis and leptomeningitis, as diagnosed by magnetic resonance imaging (MRI) (4-5).
Results:
Case report: 52 years old patient with clinical history of RA since 2022, patient developed urticarial vasculitis as complication of COVID-19 resistant to steroids and antihistaminic. In 2025, patient presents right frontal headache and hypoesthesia on left side on the body. MRI revealed bifrontal pachymeningitis and frontal-parietal interhemispheric leptomeningitis with right parasagittal predominance. The patient was admitted to hospital due to persistent headache, focal sensory symptoms and meningeal enhancement. Lumbar puncture for meningitis and encephalitis was negative; stains and cellular culture were also negative. Clinical evaluation of infectology exclude infective causes. Rheumatological testing showed elevated rheumatoid factor and cyclic citrullinated peptide (CCP), leading to a diagnosis of RM. Methylprednisone was administrated, but symptoms persisted. Second MRI showed continued pachymeningeal and leptomeningeal involvement. Patient was re-admitted to hospital and treated with intravenous immunoglobulin. Despite treatment, symptoms continued; third MRI revealed meningeal and cortical inflammation. Patient then developed seizures. Further investigations including cerebral angiography, coagulation profile, PET and flow cytometry in cerebrospinal fluid, showed negative results. Neurologist and rheumatologist decided treat the patient with monoclonal antibody (Rituximab), egress at home with methotrexate, levetiracetam and prednisone. In the next days was positive evolution, MRI showed minor signs of meningitis, without seizures and improvement in headache.
Conclusions:
Rituximab achieved clinical improvement in refractory rheumatoid meningitis with persistent symptoms.
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