A Rare Clinical Presentation of Vasculitis as a Gastrointestinal Bleed

Abstract

Introduction: Polyarteritis nodosa (PAN) is a vasculitis of medium and small-sized arteries, primarily occurring in the kidneys, and nervous system. Case: We present a 70-year-old man with two episodes of hematochezia in the last 24 hours. Patient was resuscitated with intravenous (IV) fluids, and 17 units of packed red blood cells (RBC) over the hospital course. Tagged RBC scan demonstrated evidence of active bleeding in the small bowel and the ascending colon. Angiography showed multiple pseudoaneurysms in branches of the left gastric, splenic and superior mesenteric arteries (SMA). Gastroenterology performed an upper gastrointestinal (GI) endoscopy, single balloon enteroscopy, and colonoscopy, which did not yield a source of bleed, yet the hematocrit continue to plummet. An alternate diagnosis of PAN was considered. Rheumatology suggested IV steroids, after which the patient's hematocrit stabilized with complete resolution of symptoms. Further workup demonstrated low complement supporting the diagnosis of PAN. Discussion: PAN typically presents with an array of systemic symptoms, however, a subset of patients have mesenteric arterial involvement with no clinical evidence of extraintestinal symptoms. One study demonstrated that angiographic diagnosis of PAN has a sensitivity of 89% and a specificity of 90%. In patients with severe PAN, characterized by GI bleed, IV steroids should be initiated for three days followed by other immunosuppressant therapy. In this case the patient presented with an acute lower GI bleed and no other clinical symptoms of PAN. Upon failed attempts to visualize a source of GI bleed, a mesenteric angiography demonstrated multiple pseudoaneurysms. Persistent lower GI bleed only subsided with IV steroids, resulting in an interdisciplinary consensus that his GI bleed was likely secondary to PAN. In conclusion this case demonstrates that systemic vasculitis can present with serious GI hemorrhage, even in the absence of other signs and symptoms of PAN. Mesenteric angiography clearly demonstrated that vasculitic lesions can develop and resolve rapidly with prompt, aggressive management.Figure