Rinsho Shinkeigaku (Clinical Neurology)

Case Report

Steroid responsive chronic meningoencephalitis reminiscent of rheumatoid meningitis: a case report

Satoru Morimoto, M.D.1)2), Masaki Takao, M.D., Ph.D.2)3), Keita Sakurai, M.D., Ph.D.4), Masako Sunagawa, M.D.5), Tadashi Komiya, M.D.6), Tomio Arai, M.D., Ph.D.7), Kazutomi Kanemaru, M.D., Ph.D.1) and Shigeo Murayama, M.D., Ph.D.1)2)

1)Department of Neurology, Tokyo Metropolitan Geriatric Hospital and Institution of Gerontology
2)Department of Neuropathology, Tokyo Metropolitan Geriatric Hospital and Institution of Gerontology
3)Department of Neurology and Stroke, Saitama Medical University International Medical Center
4)Department of Radiology, Nagoya City University
5)Department of General Medicine, Tokyo Metropolitan Geriatric Hospital and Institution of Gerontology
6)Department of Neurology, National Hospital Organization Tokyo National Hospital
7)Department of Pathology, Tokyo Metropolitan Geriatric Hospital and Institution of Gerontology

A 62-year-old woman presented at our hospital with a headache, cognitive decline, and fever that had persisted for 3 months. On admission, fever, headache, and mild cognitive dysfunction were all clearly evident, suggesting chronic meningoencephalitis. Laboratory examination showed mild neutrophilia as well as an increase in her erythrocyte sedimentation rate and serum C-reactive protein levels. MRI showed multiple small hyperintense lesions on T2 weighted image and diffusion weighted image (DWI) in the cerebral cortex and white matter. Contrast-enhanced T1 weighted image showed the abnormal pial enhancement along the cerebral sulci. Systemic evaluations for infectious organisms, autoantibodies, and malignant tumors were all negative. Her fever and neurological symptoms continued. As a result of worsening MRI findings, a brain biopsy was carried out. Neuropathological analysis revealed neutrophilic infiltration in the subarachnoid space and multinucleated giant cells. However, there was no vasculitis on the histological sections. This pathological finding was reminiscent of rheumatoid meningitis despite articular findings of rheumatoid arthritis, as well as rheumatoid factor (RF) and anti-CCP antibody tests being negative. After oral steroid therapy, her fever and inflammatory reactions by laboratory test diminished and her cognitive function improved remarkably.
Full Text of this Article in Japanese PDF (1008K)

(CLINICA NEUROL, 55: 573|579, 2015)
key words: chronic meningitis, neutrophilic infiltration, multinucleated giant cell, brain biopsy, steroid therapy

(Received: 11-Feb-15)