Can Rheumatoid Arthritis (RA) Cause Inflammation of the Brain?

Rheumatoid arthritis (RA) is a chronic, inflammatory disease in which the immune system mistakenly attacks the lining of the membrane that surrounds joints, particularly the smaller joints of the hand and wrist, although larger joints such as the shoulders, hips, and knees may become involved later in the disease. The autoimmune reaction also affects other organs and tissues in the body.

RA is estimated to affect up to one percent of the population worldwide.

Most joints are covered with a lining called the synovium, which lubricates the joint for easy movement.

In RA, the synovium becomes inflamed (synovitis), thickens, and produces an excess of joint fluid. This fluid along with the inflammatory chemicals released by the immune system causes swelling, damages cartilage, and softens the bone within the joint. 

The swollen tissues stretch the surrounding ligaments, resulting in deformity, instability, and weakened and damaged tendons and ligaments.

The most common signs and symptoms of rheumatoid arthritis (RA) include:

• Pain, swelling, and stiffness of the joints
• Joints are typically affected in a symmetrical pattern (both hands and feet are affected simultaneously)
• Joint pain and stiffness are worse in the morning or after a long period of rest

Rheumatoid meningitis is a serious extra-articular brain manifestation of RA.

Symptoms of brain involvement in RA may include:

• Severe headache
• Vomiting
• Seizures
• Psychosis 
• Compulsive behavior

The diagnosis of rheumatoid meningitis (RM) is challenging due to misleading presentation with stroke-like episodes or the absence of other clinical features that suggest rheumatoid arthritis (RA).

In most cases, the diagnosis of RM preceded the diagnosis of RA within the first three months of initial presentation or was diagnosed simultaneously.

• MRI: Often shows changes in the meninges (leptomeningeal and pachymeningeal enhancement) but can involve the brain parenchyma.
• Cerebrospinal fluid analysis: Typically shows lymphocytic pleocytosis (an abnormal increase in lymphocyte count in the cerebrospinal fluid).
• Meningeal biopsy: Positive findings involve necrotizing granulomas consistent with RM.
• Rheumatoid factor and anticyclic citrullinated peptide antibodies: Both are characteristically elevated in RA.

Other conditions that resemble rheumatoid meningitis include:

• Infectious or carcinomatous meningitis
• Drug-induced, viral, or autoimmune meningitis
• Subdural or subarachnoid hemorrhage
• Systemic lupus erythematosus 
• Sarcoid and Behçet disease
• Granulomatosis with polyangiitis
• Giant cell arteritis
• Sjogren syndrome
• Immunoglobulin G4-related meningitis

Unfortunately, there are no clear guidelines for the treatment of rheumatoid meningitis. Treatment usually involves high-dose corticosteroids or immunomodulatory therapy, or both.

• Nonsteroidal anti-inflammatory drugs
  • Ibuprofen
  • Naproxen 
  • Aspirin
• Disease-modifying antirheumatic drugs
  • Methotrexate
  • Tocilizumab
  • Cyclophosphamide 
  • Rituximab
• Glucocorticoids
  • Prednisone

In severe cases, affected individuals may develop abnormal inflammation that leads to severe joint damage, which limits movement and can cause significant disability.

A few other complications include:

• Rheumatoid nodules (tiny firm bumps that develop around the pressure areas such as the elbows and finger joints)
• Dry eyes and mouth (a disorder characterized by a decrease in the amount of moisture in the eyes and mouth)
• Carpal tunnel syndrome (compression of the median nerve leading to numbness and tingling pain in the hand and forearm)
• Osteoporosis
• Heart problems
• Lung disease
• Lymphoma (cancer in the lymph system)