Case Summary
A 61-year-old man presented with right-sided somatosensory seizures and evidence of left-sided pachymeningeal enhancement on a cerebral MRI (figure, A–C). The patient had a seizure 12 years prior. Upon review of the previous MRI, similar inflammatory changes in the contralateral hemisphere were seen (figure, D–E). Serologic and cerebrospinal fluid analysis and a brain PET scan demonstrated no abnormality. Brain biopsy revealed chronic lymphohistiocytic meningitis. His episodic arthropathy prompted rheumatological workup that revealed elevated cyclic citrullinated peptide and rheumatoid factor, suggestive of palindromic rheumatism, with corresponding imaging findings reminiscent of those described with rheumatoid meningitis.1,2 He improved after a brief course of steroids with resolution of meningeal enhancement (figure, F).
(A–F) Demonstrate MRI sequences from 3 different time points, respectively. The pattern of cortical hyperintensity and enhancement in the left hemisphere from 2016 (A–C) compares with the predominantly right hemispheric involvement in 2004 (D–E), with inflammation resolving 3 months later (F).
Study Funding
None.
Disclosure
Dr Ahmed Itrat, Dr Rula A. Hajj-Ali, and Asma Akbar Ladak report no disclosures. Go to Neurology.org/N for full disclosures.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Teaching Slides links.lww.com/WNL/B450
- © 2021 American Academy of Neurology
Letters: Rapid online correspondence
- Author Response: Teaching NeuroImage: Palindromic Rheumatoid Meningitis: A Tale of 2 Hemispheres
- Reader Response: Teaching NeuroImage: Palindromic Rheumatoid Meningitis: A Tale of 2 Hemispheres
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