Anti-phospholipid syndrome is a relatively common autoimmune hypercoagulable disorder characterized by recurrent thrombosis in the presence of anti-cardiolipin and anti β-glycoprotein antibodies.

Meningeal thickening is classically associated with tumors, infections such as meningitis and tuberculosis or inflammatory conditions such as sarcoidosis and Granulomatosis with polyangiitis.

We present a 46 year old lady with a complicated background history. She was diagnosed with antiphospholipid syndrome after a DVT and PE in 2018 with positive β2-glycoprotein and negative anti-cardiolipin antibodies.

She has a significant neurological history and has attended Neurology outpatient clinics for 10 years. She has a longstanding diagnosis of migraine and has been diagnosed with psychogenic non epileptic seizures after an EMU admission in 2018 as well as functional intermittent left hemiparesis. She has previously had unremarkable MRI imaging of her Brain in 2015

A repeat MRI Brain in January 2019 revealed diffuse left sided meningeal thickening. Serum ACE was elevated at 127 (8-53) but CSF was unremarkable and CSF ACE negative. PET body showed splenomegaly and stable lymphadenopathy.  An inguinal lymph node biopsy showed no evidence of malignancy or granulomas.

A repeat MRI Brain in March 2019 showed complete interval resolution of the previously described meningeal thickening.

There have been a few recent cases of antiphospholipid syndrome with pachymeningitis described previously^1,2. In our case, the patient has been polysymptomatic with recurrent headaches, dizziness and intermittent weakness for several years and therefore there was no clear discrete episode of meningitis on history. We felt that sarcoidosis was ruled out based on our investigations and that the elevated serum ACE was an epiphenomenon. Our case highlights the clinical dilemmas and difficulty in investigating organic neurological disease on a significant history of somatoform disorders. We are also adding to the literature with another description of reversible meningeal thickening with Antiphospholipid syndrome.