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An unusual cause of meningitis

A 57 year old man patient presented with fever and frontal headache. He had a background history of sero-positive rheumatoid arthritis which was well controlled on immunomodulatory disease modifying anti-rheumatoid drugs (DMARDS) including methotrexate and leflunomide. Six months earlier he had returned from Massachussetts in the USA after a one year period of residence there. On examination his vital signs were within normal limits and he was afebrile with a temperature of 36.1o C. His left elbow joint was warm, tender and swollen; examination was otherwise normal.

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