Abstract：
Rheumatoid meningitis (RM) is a rare complication of rheumatoid arthritis that can manifest as stroke-like episodes. We present the case of a 63-year-old woman with a past history of overlap syndrome and clinical manifestations suggestive of amyopathic dermatomyositis, rheumatoid arthritis, and systemic lupus erythematosus. She presented to the emergency department with sudden onset right-sided clumsiness and numbness, as well as a 2-week history of left hemicranial headache. Laboratory workup revealed positive serum antinuclear antibodies, anti-Ro antibodies, anti-citrullinated peptide antibodies (ACPA), and elevated rheumatoid factor. Lymphocytic pleocytosis, positive ACPA and anti-Ro antibodies with passive diffusion pattern, and negative microbiological studies were demonstrated in the CSF. Brain magnetic resonance imaging showed predominant left fronto-parieto-occipital leptomeningeal and pachimeningeal enhancement. She was diagnosed with RM and received methylprednisolone IV mg/kg once daily. Stroke-like episodes in the setting of a patient with lymphocytic pleocytosis in the cerebrospinal fluid (CSF) and meningeal enhancement should raise suspicion of RM. In this context, serum rheumatoid factor and ACPA levels should always be measured and ACPA should also be measured in CSF. To our knowledge, this is the first reported case of RM in the context of an overlap syndrome. ACPA levels in CSF could be a relevant diagnostic clue in the setting of central nervous system disturbance and overlapping autoimmune conditions that include rheumatoid arthritis. In our case, the presence of a suggestive clinical scenario of RM reinforces the probable pathogenic role of ACPA when it is present in the central nervous system, even without intrathecal synthesis evidence.
摘要：
类风湿性关节炎（RM）是类风湿性关节炎（RA）的罕见并发症，可表现为中风样发作。我们介绍了一名63岁的女性，其既往有重叠综合征（OS）病史，临床表现提示肌病性皮肌炎，类风湿性关节炎,和系统性红斑狼疮。她突然出现右侧笨拙和麻木，并有2周的左半脑型头痛史。实验室检查显示血清抗核抗体（ANA）阳性，抗Ro抗体，抗瓜氨酸肽抗体（ACPA），和类风湿因子(RF)升高。淋巴细胞增多症,具有被动扩散模式的ACPA和抗Ro抗体阳性，和阴性的微生物学研究在CSF中被证明。脑部MRI显示主要是左额顶枕骨软脑膜和钩膜增强。我们诊断为RM，并开始每天一次静脉注射甲基强的松龙mg/kg。在脑脊液淋巴细胞增多和脑膜增强的患者中，中风样发作应引起对RM的怀疑。在这种情况下，应始终测量血清RF和ACPA水平，也应在CSF中测量ACPA。据我们所知,这是在操作系统背景下报告的第一个RM案例。CSF中的ACPA水平可能是中枢神经系统（CNS）紊乱和包括RA在内的重叠自身免疫性疾病的相关诊断线索。在我们的案例中,提示RM的临床情景的存在加强了ACPA在CNS中可能的致病作用，即使没有鞘内合成的证据。
