Localized, single-organ vasculitis: clinical presentation and management

A 51-Year-Old Man With Dyspnea and a Pulmonary Nodule

CASE PRESENTATION

A 51-year-old man presented with chest tightness, exertional dyspnea, and occasional chest pain for 2 years. The patient visited his local hospital initially, and CT scan revealed a ground glass opacity (GGO) located in the right upper lobe (Fig 1A). He was diagnosed as having pulmonary infection and treated with levofloxacin for 12 days. A repeated chest CT scan 14 days later demonstrated a progressed solid nodule with surrounding ground glass opacity (Fig 1B). With a suspicion of carcinoma in situ, right upper lobectomy was performed via video-assisted thoracoscopic surgery at the local hospital. However, the histologic examination did not show any evidence of malignancy, and the symptoms persisted. Fourteen months later, his dyspnea worsened with extremely low exercise tolerance. The patient denied other symptoms (eg, rash, fever, joint pain, aphthous stomatitis, genital ulceration, other symptoms of arteritis). His appetite was decreased but without significant weight loss. He did not smoke and had a history of fully recovered cerebral infarction 9 months ago. There was no family history of respiratory diseases. After 4 months, a CT pulmonary angiography scan revealed filling defects at the left pulmonary artery and left inferior pulmonary artery (Fig 2A). A vascular narrowing was detected at the left superior pulmonary artery. Accompanied with an increased D-dimer level (> 10 mg/L; normal range, 0-0.5 mg/L), a diagnosis of pulmonary embolism was made. The patient was treated with warfarin, and his symptom of dyspnea was partially relieved. He came to our hospital for further treatment 4 months later.

Navigating mesenteric vasculitis: A comprehensive review of literature

Vasculitides are diseases marked by inflammation of the blood vessel walls across various organ systems. The mesenteric vasculitis (MV) affects localized mesenteric vessels of the gastrointestinal tract. It usually occurs as part of a systemic inflammatory process but could also present in isolation. There are very few published reports of isolated mesenteric artery vasculitis. Presenting symptoms often include nausea, vomiting, diarrhea, abdominal pain, rectal bleeding, often complicating the diagnostic process. Diagnosing MV as the cause of abdominal pain can be challenging, and failure to diagnose can result in significant morbidity and mortality. A timely and accurate diagnosis of MV is essential for administering the appropriate immunosuppressive therapy and preventing unnecessary surgical interventions. This review aims to provide a comprehensive discussion of MV, including its clinical presentation, diagnostic approaches, and treatment options, with a focus on achieving early diagnosis to enhance outcomes and prevent complications. Furthermore, this review addresses the diagnostic challenges associated with MV, including the lack of specific criteria and symptom overlap with other gastrointestinal disorders such as atherosclerotic mesenteric ischemia, infections, malignancies, adverse medication effects, and other vessel occlusive processes. It also emphasizes the gaps in current literature regarding optimal diagnostic strategies and the necessity for standardized treatment protocols. By addressing these gaps and challenges, we aim to optimize patient care and improve prognosis for individuals affected by MV.

Isolated inferior thyroidal artery vasculitis: A rare cause of neck pain

Vasculitis is the inflammatory changes in vessels of any size that usually have a systemic involvement with a quite variable clinical presentation affecting various organs. Although systemic presentation is more common, in some cases localized inflammation of vasculature of a single organ or limited branches of aorta are reported. Here we present, an isolated vasculitis of bilateral inferior thyroidal arteries in a female patient aged 49 years, who presented with neck pain and was diagnosed with ultrasonography and computed tomographic angiography. The clinical and imaging findings were managed successfully with glucocorticoid induction and addition of methotrexate to the treatment. Localized forms of vasculitis are rarer and the limited size of the affected area makes diagnostic investigations and management more complicated. Non-invasive imaging modalities rather than conventional angiography provide useful information in a safer and easier way. Isolated vasculitis of thyroidal arteries is an extremely uncommon site and should be excluded in case of unexplained neck pain, even in the presence of normal laboratory examinations, probably because of the size of the involved vessels.

Expect the Unexpected: A Rare Case of Isolated Superior Mesenteric Artery Vasculitis

Vasculitis of the mesenteric vessels is considered rare and typically occurs as a part of systemic inflammation. Isolated mesenteric artery vasculitis without systemic involvement is rarely reported in the literature. Clinical presentation is usually nonspecific which can range from abdominal pain, nausea and vomiting to gangrene and intestinal perforation in severe cases. Recognizing mesenteric artery vasculitis as a potential cause of abdominal pain can be challenging, and delay in diagnosis can lead to significant mortality and morbidity. Herein, we present a case of a 19-year-old male who initially presented with abdominal pain. Later, isolated superior mesenteric artery (SMA) vasculitis was confirmed by CT angiography. Treatment with systemic steroids alone resulted in a marked improvement in the patient's symptoms as well as in radiographic findings.

Single organ hepatic artery vasculitis as an unusual cause of epigastric pain: A case report

BACKGROUND

Single-organ vasculitis (SOV) is characterized by inflammation of a blood vessel, affecting one organ, such as the skin, genitourinary system, or the aorta without systemic features. Gastrointestinal SOV is rare, with hepatic artery involvement reported only in two prior published cases. Herein, we presented a case of isolated hepatic artery vasculitis presenting after Pfizer-BioNTech mRNA corona virus disease 2019 (COVID-19) vaccination.

CASE SUMMARY

A 50-year-old woman with hypertension presented to our Emergency Department with recurrent diffuse abdominal pain that localized to the epigastrium and emesis without diarrhea that began eight days after the second dose of the Pfizer-BioNTech COVID-19 vaccine. Blood work revealed an elevated C-reactive protein (CRP) of 19 mg/L (normal < 4.8 mg/L), alkaline phosphatase 150 U/L (normal 25-105 U/L), gamma-glutamyl transferase (GGT) 45 U/L (normal < 43 U/L) and elevated immunoglobulins (Ig) G 18.4 g/L (normal 7-16 g/L) and IgA 4.4 g/L (normal 0.7-4 g/L). An abdominal computed tomography revealed findings in keeping with hepatic artery vasculitis. A detailed review of her history and examination did not reveal infectious or systemic autoimmune causes of her presentation. An extensive autoimmune panel was unremarkable. COVID-19 polymerase chain reaction nasopharyngeal swab, human immunodeficiency virus, viral hepatitis and Heliobacter pylori serology were negative. At six months, the patient’s symptoms, and blood work spontaneously normalized.

CONCLUSION

High clinical suspicion of SOV is required for diagnosis in patients with acute abdominal pain and dyspepsia.

Isolated Multifocal Superior Mesenteric Artery Vasculitis With Coexisting Superior Mesenteric Vein Thrombosis: A Unique Coincidence

Vasculitis involving the gastrointestinal (GI) tract typically occurs in association with multisystem disease. Isolated superior mesenteric artery (SMA) vasculitis is a rare disorder that has a high degree of morbidity and mortality. Patients often present with nonspecific symptoms, and this condition can lead to varying degrees of intestinal ischemia, significant gastrointestinal bleeding, and bowel infarction, leading to perforation, peritonitis, and sepsis from bacterial translocation. Diagnosing this condition can be very challenging. High clinical suspicion and early diagnosis using both laboratory workup and appropriate vascular imaging are pivotal in improving outcomes in such patients. Herein, we describe the case of isolated yet multifocal SMA vasculitis with coexisting superior mesenteric vein (SMV) thrombosis. Medical therapy alone resulted in clinical and radiographic improvements. To our knowledge, there have not been any previous reports of this unique coexistence.

Testicular vasculitis: a diagnostic conundrum

Vasculitis is rare in the context of testicular lesions but, when found, can be classified as a single organ vasculitis or part of a multi-organ inflammatory process. In the context of a patient with a pre-existing autoimmune disorder, this finding might cause diagnostic confusion and preferentially bias a physician towards attributing the condition to the known diagnosis or its treatment. This diagnostic bias can interfere with patient care and lead to over caution, resulting in a worse outcome for the patient involved. We describe such a patient with rheumatoid arthritis on biologic therapy.

Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis (AAV) Restricted to the Limbs

A previously healthy 58-year-old man was admitted for muscle pain and weakness [manual muscle testing (MMT) of 4/4 for upper and lower limbs]. We detected elevated levels of inflammatory makers and PR3-anti-neutrophil cytoplasmic antibody (ANCA). Subsequently, the muscle weakness rapidly progressed to an MMT of 2 for all limbs. Magnetic resonance imaging indicated muscle edema, and the creatine kinase (CK) level increased to 29,998 U/L. Methylprednisolone (mPSL) and cyclophosphamide pulse therapy improved the patient symptoms. MMT recovered to 4 for all limbs. A muscle biopsy showed degenerated muscle fibers surrounded by neutrophil-predominant infiltration. In addition, lamina elastic breakdown and fibrinoid necrosis of arterioles were observed. A final diagnosis of microscopic polyangiitis (MPA) limited to the muscles was made.