Unusual aseptic meningitis and cognitive syndrome in a patient under anti-TNF therapy for rheumatoid arthritis: a case report
Notice bibliographique
Résumé
Case presentation: A 66-year-old female retired lawyer, with a past medical history of rheumatoid arthritis (RA) treated with Golimumab for the last 10 months, with behavioral change in the past two months, after a single dose of intra-articular corticosteroid due to articular pain. Her family claims that she became progressively agitated, easily irritated and euphoric, and made excessive expenses. She was taken to a psychiatrist and started on olanzapine and valproic acid. Subsequently, her humor became depressed, with a feeling of anguish and loss of interest in her usual activities. Due to progression, she was taken to the emergency department. Her neurological exam was only remarkable for a cognitive impairment, scoring 21 out of 30 points in the Montreal Cognitive Assessment (MoCA), with losses in visuospatial function, attention, delayed recall and orientation. Her CSF showed a mild increase in cellularity of 7 and proteins of 58, and a brain MRI showed aseptic meningitis (AM). Considering her immunosuppressed status, she was started on empirical acyclovir, ceftriaxone and ampicillin, without improvement. A CSF metagenomic was negative. Paraneoplastic investigation was also unremarkable. As an alternative diagnosis, we considered the possibility of Golimumab being the trigger for the AM; therefore, the medication was stopped and she received a course of IVIg followed by IV methylprednisolone. Upon discharge, brain MRI and MoCa improved, and on outpatient follow-up, she no longer had remarkable findings on neuroimaging and her MoCA evaluation was 28/30. Discussion: RA can cause meningitis, but its treatment can also be linked to AM by direct effect or leading to infectious meningitis due to the immunosuppressive effect. 23 cases of RA patients developing AM due to the use of anti-TNF medications were found by Yıldırım, R. et al., with half of them within the first year of exposure. There are no specific findings that differentiate rheumatoid AM from anti-TNF-induced AM, but the development of the condition after starting treatment suggests the later. Since anti-TNF agents cannot cross the blood-brain barrier, it is thought that the inhibition of tumor necrosis factor (TNF) results in paradoxical increase in its concentration within the CNS. Additionally, it can lead to immune dysregulation by inhibiting the apoptosis of self-reactive T cells. There is no consensus on treatment, but discontinuation of the precipitating drug and high-dose corticosteroids are the most common initial choices. Final comments: AM gives rise to a series of possible differential diagnoses, so a thorough investigation is mandatory. Special attention was paid to infectious etiologies, and we only pursued immunotherapy after a negative study of her CSF. It’s a known fact that medications can cause AM, and anti-TNF, already linked to a series of other neurological diseases, has to be on the list of causes when evaluating a patient.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,004 |
| Méta-épidémiologie (sens strict) | 0,003 | 0,001 |
| Méta-épidémiologie (sens large) | 0,002 | 0,001 |
| Bibliométrie | 0,004 | 0,003 |
| Études des sciences et des technologies | 0,004 | 0,002 |
| Communication savante | 0,003 | 0,003 |
| Science ouverte | 0,001 | 0,002 |
| Intégrité de la recherche | 0,007 | 0,004 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».