Polyarteritis Nodosa: Gangrene in a Rheumatoid Arthritis Patient.

Abstract

A 67-year-old Japanese woman with rheumatoid arthritis of 30 years duration presented with digital gangrene (Fig. 1) and diarrhea. The conventional angiography showed a left medial plantar artery aneurysm (an arrow, Fig. 2A), a left renal artery aneurysm (an arrow, Fig. 2B), and an ileocolic artery aneurysm (an arrow, Fig. 2C). Based on her symptoms and the results of the conventional angiography, she was diagnosed with polyarteritis nodosa. Gangrene of the lower limb in a patient with rheumatoid arthritis might suggest rheumatoid vasculitis or arterial occlusive disease, but both were unlikely due to the negative rheumatoid factor and the absence of atherosclerosis on computed tomography. Polyarteritis nodosa is typically a medium-sized vasculitis with visceral artery aneurysms, but microaneurysms may not be detectable on computed tomography or magnetic resonance imaging. In such cases, it may be advisable to perform conventional angiography to diagnose before organ damage occurs.FIGURE 1: Digital gangrene.FIGURE 2: The conventional angiography: (A) a left medial plantar artery aneurysm, (B) a left renal artery aneurysm, and (C) an ileocolic artery aneurysm.DIFFERENTIAL DIAGNOSIS Rheumatoid vasculitis, arterial occlusive disease, granulomatosis with polyangiitis, Behçet syndrome