New-onset seizures: an unusual neurologic manifestation of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory condition primarily affecting the musculoskeletal system but can often involve other organ systems as well. Rheumatoid meningitis is a rare central nervous system (CNS) manifestation of RA characterized by pachymeningeal and leptomeningeal enhancement. Herein, we present a case of a 64-year-old male who presented with left lower extremity weakness and witnessed seizures. The diagnostic work-up, including lumbar puncture, brain MRI and meningeal biopsy ruled out malignancy and were consistent with the diagnosis of rheumatoid meningitis. The patient was discharged on high-dose steroids along with anti-seizure medications. On subsequent follow-up visits, the patient remained seizure-free.

Protothecal olecranon bursitis: an unusual algal infection.

Prototheca is an achlorophyllic alga which rarely causes infections in humans and protothecal olecranon bursitis is remarkably rare. We report a case of a 76-year-old immunocompetent man presenting with pain and swelling of the right elbow secondary to protothecal infection. Initial cultures of the olecranon bursal aspirate revealed no growth; however, repeat aspiration after 2 months grew prototheca species on culture. Prototheca wickerhamii and Prototheca zopfii are the only 2 protothecal species known to cause human infections. Protothecal infection can manifest as skin infections, extremity infections, bursitis and very rarely as systemic infections. Treatment of protothecal infections remains controversial. Amphoterecin B, ketoconazole and fluconazole have been reported to yield a successful outcome. More recently, itraconazole has been found to be curative. Surgical excision of the bursa remains the definitive treatment. Our patient was treated with itraconazole with a favorable response.

Rituximab is useful in the treatment of Felty's syndrome.

Felty's syndrome is regarded as a severe variant of rheumatoid arthritis (RA) that develops in less than 1% of patients with RA. It consists of a triad of RA, splenomegaly, and leukopenia, which tends to develop after a long course of RA. Treatment of neutropenia is mainly comprised of disease-modifying antirheumatic drugs including methotrexate, hydroxychloroquine, auronofin, penicillamine, glucocorticoids, and granulocyte monocyte colony stimulating factor. Recently, there has been a growing interest in the biologic agent rituximab in the treatment of Felty's syndrome. To our knowledge, only one previous case of rituximab being beneficial in the treatment of Felty's syndrome has been reported. We report the case of a 60-year-old man with Felty's syndrome in whom treatment with rituximab led to a sustained neutrophil response and marked symptomatic improvement in the form of decrease in the size of rheumatoid nodules and better pain control.