Concurrent cutaneous polyarteritis nodosa and arteritis temporalis in a 68-year-old woman

Abstract

Funding sources: None. Conflicts of interest: None declared. Dear Editor, Cutaneous polyarteritis nodosa (CPN) is a rare vasculitis affecting the small and medium arteries in the reticular dermis and subcutaneous tissue. CPN should be distinguished from systemic polyarteritis nodosa (PAN), which is an aggressive systemic vasculitis with internal organ involvement. Extracutaneous findings of CPN include fever, myalgia, arthralgia and neuropathy.1 In contrast, temporal arteritis (TA) or giant‐cell arteritis (GCA) is a vasculitis that involves the medium and large arteries, and may develop together with polymyalgia rheumatica.2 An overlapping vasculitic syndrome of PAN and TA has been reported in the literature.3 4 5 6 7 8 To our knowledge, CPN with TA has only been described in one previous case report.9 We report a 68‐year‐old woman who presented with livedo reticularis with necrotic centres in a starburst pattern on the back, chest and upper arms of 3‐week duration (Fig. 1). Extracutaneous findings included fever, myalgia and weakness in the thighs. She had no other neurological symptoms or symptoms from the gastrointestinal or genitourinary tract. She also denied having any cardiopulmonary symptoms. Her medical history included long‐term treatment for depression. A punch biopsy was performed on the upper arm and she was started on prednisolone 50 mg daily. Laboratory tests revealed normal haemoglobin, slightly elevated C‐reactive protein (CRP), erythrocyte sedimentation rate (ESR) and leucocytosis. Urine analysis, s‐creatinine, glomerular filtration rate and creatine kinase were normal. Hepatitis A, B and C serology were negative. Immunoglobulin levels, cryoglobulins, antinuclear antibody, antineutrophil cytoplasmic antibody and rheumatoid factor were normal. Echocardiography and bone marrow aspirate were normal. A computed tomography (CT) scan of the chest, abdomen and pelvis showed no sign of malignancy. A 18F‐fluorodeoxyglucose–positron emission tomography scan revealed a rectal adenoma, which was surgically removed. Histology of the punch biopsy showed vasculitis in the small and medium arteries in subcutaneous tissue (Fig. 2a, b), which are typical findings of PAN. An abdominal angiography showed no involvement of the abdominal vessels. A revised final diagnosis of CPN was made. The patient improved on prednisolone treatment, which was tapered off over the next few months. The cutaneous ulcers healed and the other symptoms disappeared. She had no further relapse.