Teaching NeuroImages: Palindromic Rheumatoid Meningitis: A Tale of Two Hemispheres

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 seizure 12 years prior. Upon review the previous MRI, similar inflammatory changes in contralateral hemisphere were seen D–E). Serologic cerebrospinal fluid analysis brain PET scan demonstrated no abnormality. Brain biopsy revealed chronic lymphohistiocytic meningitis. His episodic arthropathy prompted rheumatological workup that elevated cyclic citrullinated peptide rheumatoid factor, suggestive palindromic rheumatism, corresponding imaging findings reminiscent those described meningitis.1,2 He improved after brief course steroids resolution meningeal F).