最终诊断及更多知识

The patient was finally diagnosed with rheumatoid meningitis presenting with a stroke-like attack (RMSA). On day 16, continuous infusion of methylprednisolone 1000 mg daily was started for 3 days, and it was repeated on day 28. Her symptoms then gradually resolved, and the high signal on the FLAIR image also disappeared. The patient was discharged on day 44 with only a slight attention deficit on neurological examination.

患者最终被诊断为类风湿性脑膜炎，表现为卒中样发作。第16天开始持续输注甲基强的松龙1000 mg/d，连续3d，第28天重复治疗一次。她的症状逐渐缓解，FLAIR图像上的高信号也消失了。患者于第44天出院，神经系统体格检查仅有轻微注意力缺陷。

Rheumatoid meningitis (RM) is defined as a condition of inflammation of the meninges or dura mater with cell infiltration. In the past, most RM cases were reported as autopsy cases, but the number of reported cases of RM has increased along with the increase in patients with long-standing disease and advances in diagnostic imaging. In many patients, RA is in the very early stage or long-term, and the disease duration is said to be ≥10 years for 50% or more. The present patient presented 6 months after her diagnosis of RA, and thus was in the comparatively early stages of the disease; although the reason for that is not clear, it is consistent with earlier reports. In addition, although it did not correlate with her arthritic activity, the onset of RM was sudden and at a time when her RA activity was stable. There have been scattered reports of the use of intravenous steroid pulse therapy and oral steroids (1 mg/kg). Even when there is improvement with treatment, caution must be taken regarding possible relapse or recurrence, but the present patient did not relapse up to 6 months later.

类风湿脑膜炎(RM)被定义为脑膜或硬脑膜炎症并伴有细胞浸润。过去，大多数RM病例为尸检报告病例，但随着长期疾病患者的增加和诊断影像学的进步，报告的RM病例数量也有所增加。在许多患者中，RA处于非常早期或长期阶段，50%或更长病程的≥10年。该患者在被诊断为类风湿性关节炎6个月后出现，因此处于疾病的相对早期阶段；虽然原因尚不清楚，但这与前期的报道是一致的。此外，这与她的关节炎活动没有相关性，RM的发作是突然的，而且是在她的RA稳定期发生的。使用静脉类固醇脉冲疗法和口服类固醇(1 mg/kg)的报道甚少。即使治疗有所改善，也必须注意可能的复发或复发，但目前的患者在6个月后没有复发。

The neurological symptoms of RM may be hemiplegia, monoplegia, impaired consciousness, psychiatric symptoms, convulsions, and sensory impairment. These symptoms are usually slowly progressive or transient. However, to the best of our knowledge, there have been only two reports of patients with stroke-like attacks. Thus, although rare, Rheumatoid meningitis presenting with a stroke-like attack should be included in the differential diagnosis of acute ischemic stroke presenting within the time window for thrombolytic therapy. The present patient is the first reported case of Rheumatoid meningitis presenting with a stroke-like attack who was treated with rt-PA. MRI is helpful to differentiate it from acute ischemic stroke when it is performed on hospitalization.

RM的神经症状可能是偏瘫、单瘫、意识障碍、精神症状、抽搐和感觉障碍。这些症状通常是缓慢进展或一过性的。然而，据作者而知，截止2018年该文章发表前只有两例患者中风样发作的报告。因此，尽管罕见，但表现为卒中样发作的类风湿性脑膜炎应包括在溶栓治疗时间窗内出现的急性缺血性卒中的鉴别诊断中。本患者是首例报告的类风湿性脑膜炎，表现为卒中样发作并接受了rt-PA治疗。入院时行MRI检查有助于与急性缺血性卒中的鉴别。

The present patient’s symptoms rapidly improved in the early treatment period. It is possible that the brain-protective agent, edaravone, which was co-administered with intravenous rt-PA, contributed to that improvement. Free radicals have been reported to be involved in the vasculitis and cerebral edema associated with encephalitis as well, and to some extent, the administration of edaravone, a free radical scavenger, makes sense. MRI and biopsy findings have primary importance in the diagnosis of RM. A meningeal biopsy was not performed in the present case because of the rapid improvement of symptoms. However, the MRI findings were typical for RM, with a restricted ADC at the subarachnoid space adjacent to the right frontotemporal cortex. This linear high-intensity lesion on DWI is thought to result from proteinaceous debris accumulation at the subarachnoid space adjacent to the parenchyma with meningeal lymphocytic infiltration

这位患者的症状在早期治疗期后迅速改善。可能是脑保护剂依达拉奉与静脉注射rt-PA联合使用，促成了这种改善。据报道，自由基也与脑炎相关的血管炎和脑水肿有关，在某种程度上，使用自由基清除剂依达拉奉是有意义的。MRI和活检对RM的诊断具有重要意义。由于症状迅速改善，本病例未进行脑膜活检。然而，MRI表现是典型的RM，右侧额颞叶皮质附近蛛网膜下腔ADC受限。DWI上的线样高信号病变被认为是由于蛛网膜下腔内蛋白碎片堆积在与实质相邻的蛛网膜下腔，并伴有脑膜淋巴细胞浸润所致。