A 64-year-old woman was suffering from
rheumatoid arthritis since the age of 57. At the age of 62, she manifested
episcleritis of the eyes and
rheumatoid nodules in the skin, and
rheumatoid factor in the blood became high. These findings indicated the presence of
systemic vasculitis, and she was treated with
prednisolone. At the age of 64, she suddenly became delirious, and T2-weighted and diffusion-weighted MR images revealed fresh
infarctions in bilateral temporal and parietal lobes of the cerebrum. MR angiography failed to show any narrowing or obstruction of large cerebral arteries. She had also high
fever and
arthralgia, and her blood showed elevated levels of white blood cells, erythrocyte sedimentation rate,
C-reactive protein,
IgG-
rheumatoid factor and
immune complex. Lumbar puncture revealed an elevated
protein level in CSF. A daily dose of 60 mg
prednisolone ameliorated these clinical and laboratory findings as well as her consciousness, disclosing disturbances in higher cortical functions including
Wernicke aphasia, disorientation, and ideomotor, ideational, and constructional
apraxia. Previous 13 reported cases of
cerebral infarction complicating
rheumatoid vasculitis were mostly described as showing multiple
infarctions in cerebral hemisphere, disturbance of consciousness, elevated
protein in CSF, and effectiveness of
steroid therapy. The present case had these characteristics, and the
cerebral vasculitis mediated by
IgG-
rheumatoid factor and
immune complex was indicated as a probable cause of multiple
cerebral infarctions.