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本文报告1例类风湿性关节炎合并累及脑膜的病人。病人为女性,54岁,出现剧烈、持续性头痛1周,并有阵发性左上肢抽搐,继而意识丧失及持久性左侧偏瘫。病人有血清阳性的类风湿性关节炎病史6年,最初以皮质类固醇治疗,但以后出现2次椎骨压缩性骨折,最近3年改用氨甲蝶呤治疗。体查:双手严重畸形,左半身轻瘫,无皮下结节,无其他方面异常。实验室检查:ESR为92,RF为670。CSF分析:中性粒细胞3个/mm3,蛋白定量32mg/dl。脑增强MRI提示临近右后顶叶和枕叶外缘片状增强。行右顶开颅做脑及脑膜活检,发现蛛网膜增厚、变黄。组织学检查发现结节灶,其中心为坏死组织,周围绕以栅状单核细胞和多核巨细胞,符合类风湿病理改变。从血管内膜开始的慢性炎症侵及脑膜血管壁。活检组织培养阴性。对炎症浸润组织进行CD20、CD450、CD68免疫染色,结果对B、T淋巴细胞和组织细胞阳性。脑实质未发现有明显病理改变。作者估计脑膜病变是类风湿性关节炎在关节外侵犯的一种表现,可能与氨甲蝶呤治疗有关。对此应用etanercept和秋水仙碱治疗。随访6月,经抗惊厥治疗症状缓解,但复查MRI提示病变呈进行性变化。
This article reports 1 case of rheumatoid arthritis involving patients with meninges. The patient, female, 54 years old, had severe, persistent headache for 1 week with paroxysmal left upper extremity convulsions followed by loss of consciousness and persistent left hemiplegia. The patient had a history of seropositive rheumatoid arthritis for 6 years, initially treated with corticosteroids but later with 2 vertebral compression fractures switched to methotrexate for the last 3 years. Physical examination: both hands severe deformity, left hemiparesis, no subcutaneous nodules, no other abnormalities. Laboratory tests: ESR 92, RF 670. CSF analysis: 3 neutrophils / mm3, protein quantification 32mg / dl. Brain enhanced MRI tips adjacent to the right parietal lobe and occipital lobe sheet enhancement. The right top craniotomy brain and meningeal biopsy and found that arachnoid thickening, yellowing. Histological examination revealed nodules, the center of the necrotic tissue around the grid-like mononuclear cells and multinucleated giant cells, in line with rheumatoid pathological changes. Chronic inflammation from the intima of the blood vessels invades the wall of the meninges. Biopsy tissue culture negative. Inflammatory infiltration of tissue CD20, CD450, CD68 immunostaining, the results of B, T lymphocytes and tissue cells positive. Brain parenchyma did not find significant pathological changes. The authors estimate that meningeal lesions are a form of extra-articular invasion of rheumatoid arthritis and may be associated with methotrexate therapy. Apply etanercept and colchicine to this. Follow-up in June, the treatment of symptomatic relief by anticonvulsant, but the review of MRI prompted lesions were progressive changes.