Teaching NeuroImage: Palindromic Rheumatoid Meningitis: A Tale of 2 Hemispheres

Abstract

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).