An unusual cause of chronic headaches: answer

Abstract

In the setting of a negative infectious and autoimmune workup as well as a history of rheumatoid arthritis, the biopsy results supported the diagnosis of rheumatoid pachymeningitis in this patient. Rheumatoid pachymeningitis is a rare complication of rheumatoid arthritis, and few case reports exist in the literature. Rheumatoid pachymeningitis can occur without concurrent symptoms of arthritis and may present early or late in the course of rheumatoid disease [1,2]. Other neurologic complications of rheumatoid arthritis include cerebral hemorrhage, infarction, vasculitis and spinal cord compression secondary to vertebral subluxation [3,4]. There are no defined diagnostic criteria for rheumatoid meningitis. Manifestations include seizure, headache, confusion, cranial nerve palsies, cortical blindness, and sensorineural hearing loss [2,4]. MRI typically demonstrates focal or diffuse pachymeningeal and/or leptomeningeal thickening with contrast enhancement, while cerebrospinal fluid studies show mild pleocytosis, elevated protein and hypoglycorrhachia, as was seen in our patient [4]. Typically, a biopsy is performed to support the diagnosis or to rule out other etiologies. Histopathologic findings may include rheumatoid nodules, inflammatory changes in the pachymeninges and/or leptomeninges, and vasculitis [5]. Rheumatoid nodules in the dura have typically been found only on autopsy as tissue sampling is limited during biopsy, requiring that other etiologies of pachymeningitis be ruled out [2]. The differential diagnosis for