Rheumatoid arthritis with neurological involvement manifested as hemispheric masses.

right wrist. Neurological exami nation revealed that he had anomia, visual agnosia, mild right central facial palsy, right hemiparesis (Medical Research Council, MRC, grade 4/5), and right hemihypesthesia of all sensory modalities. Laboratory findings were unremarkable except for an elevated level of rheumatoid factor (238 IU/ml). A brain MRI scan disclosed 3 mass lesions in the bilateral temporal and the left periventricular regions. The lesions were hypointense in T 1 -weighted imaging, hyperintense in T 2 -weighted imaging ( fig. 1 b, c), and were not enhanced by gadolinium. The patient underwent a stereotactic biopsy of his periventricular lesion. The pathology revealed perivascular lymphocytic infiltration and reactive gliosis ( fig. 1 d, e), which were compatible with vasculitis. We initiated pulse therapy of methylprednisolone (1 g/day); however, the patient developed steroid psychosis 2 days later. We therefore discontinued the pulse therapy and administered oral prednisolone 60 mg/day instead. After 1 month of therapy, follow-up MRI disclosed regression of the 3 brain lesions ( fig. 1 f), and his symptoms improved with residual minimal right hemiparesis (MRC 4+/5). The patient’s clinical features remained stable during the subsequent 3 years of follow-up. Dear Sir, Central nervous system (CNS) involvement in patients with rheumatoid arthritis (RA) is rare. The pathological findings include rheumatoid nodule, pachyor leptomeningitis, and vasculitis of necrotizing or plexiform type [1–3] . We report a patient with the unusual presentation of multiple masses in the cerebral hemispheres which were found to be associated with lymphocytic infiltration of some cerebral vessel walls. The masses regressed after steroid treatment.