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Saghari S, Arslan K, Sordo S. Polyarteritis Nodosa With Complications: A Diagnostic Challenge and Management Dilemma. Cureus 2023; 15:e49677. [PMID: 38033446 PMCID: PMC10686717 DOI: 10.7759/cureus.49677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/02/2023] Open
Abstract
Polyarteritis nodosa (PAN) is a rare autoimmune vasculitis characterized by the inflammation of medium-sized arteries throughout the body. This case report presents the clinical course of a 48-year-old female patient who experienced a complex diagnostic journey and complications during the management of PAN. The patient initially presented with dry skin, rash, and pruritus, which led to an extensive evaluation. Despite multiple visits and investigations, the definitive diagnosis of PAN was delayed. Eventually, the patient was diagnosed with PAN based on skin biopsy findings demonstrating vasculitis and inflammation of blood vessel walls. The treatment course was further complicated by the development of steroid-induced diabetes and recurrent vasculitis symptoms. Recurrence of symptoms, including rashes and neuropathy, necessitated adjustments in therapeutic interventions. This case highlights the challenges encountered in managing both PAN and its associated complications and emphasizes the importance of a multidisciplinary approach and improved patient compliance to optimize treatment outcomes.
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Affiliation(s)
- Saviz Saghari
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Kudret Arslan
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Sarah Sordo
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
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2
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Roy D, Sathyanarayana VA, Nagaraju B, Rao VKR. Tofacitinib as monotherapy in cutaneous polyarteritis nodosa: a case series. Rheumatol Adv Pract 2023; 7:rkad049. [PMID: 37325248 PMCID: PMC10267297 DOI: 10.1093/rap/rkad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
Objective Cutaneous polyarteritis nodosa (CPAN) is a distinct clinical entity represented by a chronic, relapsing, benign course, with rare systemic involvement. Treatment is with CSs, CYC or other conventional synthetic DMARDs (csDMARDs). In this case series, we aimed to share our varied clinical experience of successfully treating patients with CPAN, with tofacitinib in a refractory/relapsing course or as upfront monotherapy without CSs/csDMARDs. Methods We report this retrospective case series managed at our rheumatology centre in Bangalore from 2019 to 2022. Four patients identified as CPAN on biopsy were able to achieve disease-free remission with tofacitinib as part of their treatment, with no relapse on further follow-up. Our patients presented with subcutaneous nodules and cutaneous ulcers. After systemic evaluation, all the patients underwent skin biopsy, which showed fibrinoid necrosis in the vessel walls of the dermis, with a histopathological impression of CPAN. They were initially treated with a conventional approach of CSs with/without csDMARDs. On experiencing a refractory/relapsing course, tofacitinib was tried in all the patients as either CS sparing or upfront monotherapy without concomitant csDMARDs. Results Use of tofacitinib resulted in improvement of ulcers and paraesthesia and in gradual healing of skin lesions, albeit with scarring, with no further recurrence or relapse over a follow-up period of 6 months for all the patients. The therapeutic effect of tofacitinib was consistent when used either as CS sparing or as upfront monotherapy, thereby proving the drug to be a promising option that warrants larger trials in future to treat the subset of patients with established CPAN. Conclusion Tofacitinib could be used for disease-free remission as monotherapy for CPAN either upfront or as CS sparing, even without concomitant csDMARDs, in those patients who are dependent on CSs or multiple DMARDs.
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Affiliation(s)
- Debaditya Roy
- Correspondence to: Debaditya Roy, Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India. E-mail:
| | | | | | - Vijay K R Rao
- Divisha Arthritis and Medical Center, Bangalore, India
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Biswal S, Dubbudu A, Reddy GBP, Swain N, Sharawat IK, Panda PK. A Toddler with Acute Flaccid Paraparesis. Indian J Pediatr 2021; 88:931-932. [PMID: 32986158 DOI: 10.1007/s12098-020-03507-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/14/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Sebaranjan Biswal
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, India
| | - Aranya Dubbudu
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, India
| | - G Bala Praneeth Reddy
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, India
| | - Natabara Swain
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, India
| | - Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
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Martins-Martinho J, Dourado E, Khmelinskii N, Espinosa P, Ponte C. Localized Forms of Vasculitis. Curr Rheumatol Rep 2021; 23:49. [PMID: 34196889 PMCID: PMC8247627 DOI: 10.1007/s11926-021-01012-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 12/26/2022]
Abstract
Purpose of Review To provide an updated review on epidemiology, clinical manifestations, diagnostic assessment, treatment, and prognosis of localized vasculitis, following the 2012 Revised International Chapel Hill Consensus Conference Nomenclature on single-organ vasculitis. Recent Findings Localized, single-organ vasculitides encompass a group of rare conditions in which there is no evidence of concomitant systemic vasculitis. Most data on this topic derives from case reports and small case series. Although some aspects of these diseases, such as clinical manifestations and histologic findings, have already been extensively investigated, there is still a lack of robust data concerning the pathogenesis, epidemiology, and treatment. Summary Localized vasculitides may have a wide range of clinical features depending on the organ affected. The inflammatory process may have a multifocal/diffuse or unifocal distribution. Diagnosis is usually based on histopathology findings and exclusion of systemic vasculitis, which may frequently pose a challenge. Further research on treatment is warranted.
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Affiliation(s)
- Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal. .,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nikita Khmelinskii
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Pablo Espinosa
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
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Abstract
Erythematous painful cutaneous nodular lesions are associated with a host of disorders that may erupt acutely as a generalized or localized dermatitis or be associated with chronic and/or recurrent illnesses. This review discusses such disorders presenting with painful nodular lesions and attempts to provide a systematic approach to their clinical diagnosis.
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Affiliation(s)
- Arun C Inamadar
- Department of Dermatology, Venereology & Leprosy, Shri B. M. Patil Medical College, Hospital & Research Center, BLDE Deemed University, Vijayapur, Karnataka, India.
| | - Keshavmurthy A Adya
- Department of Dermatology, Venereology & Leprosy, Shri B. M. Patil Medical College, Hospital & Research Center, BLDE Deemed University, Vijayapur, Karnataka, India
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Alquorain NAA, Aljabr ASH, Alghamdi NJ. Cutaneous Polyarteritis Nodosa Treated with Pentoxifylline and Clobetasol Propionate: A Case Report. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2019; 6:104-107. [PMID: 30787830 PMCID: PMC6196709 DOI: 10.4103/sjmms.sjmms_148_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cutaneous polyarteritis nodosa is a rare type of cutaneous vasculitis. It affects the small- and medium-sized arteries of the dermis and subcutaneous tissue without extracutaneous involvement. The diagnosis is by skin biopsy, and the characteristic finding is a leukocytoclastic vasculitis. We report a case of a 14-year-old Saudi girl who was referred to the dermatology service because of multiple ulceronecrotic lesions on the frontal aspects of the distal lower limbs. She had past medical consultations and treatment but without improvement. The histopathology confirmed the clinical diagnosis of cPAN, and ultimately, she responded to treatment with pentoxifylline and topical clobetasol propionate. It is important to be aware of this disease and refer the patient to the dermatology service for the appropriate evaluation and treatment.
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Affiliation(s)
- Nada Abdulaziz A Alquorain
- Department of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdullah Salih H Aljabr
- Department of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nada Juman Alghamdi
- Department of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Cutaneous Polyarteritis Nodosa: Uncommon and Rare Form of Cutaneous Vasculitis. SERBIAN JOURNAL OF DERMATOLOGY AND VENEREOLOGY 2018. [DOI: 10.2478/sjdv-2018-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Cutaneous polyarteritis nodosa (CPAN) is a variant of polyarteritis nodosa that is limited primarily to the skin. It is a chronic recurrent disorder characterized by the presence of nodular lesions with or without ulceration on the distal third of the lower limbs. Nodular vasculitis and thrombophlebitis can be clinically or pathologically mistaken for CPAN. We present a case of a 51-year-old woman with painful nodules on the lower limbs. Some of the nodules were ulcerated. Histopathological examination of a nodule on deep incisional biopsy revealed fibrinoid necrosis of a medium-sized artery in the subcutis along with perivascular mixed infiltrate. The patient did not have any symptoms or signs of internal organ involvement. The possible etiological factor has not been detected. The patient was treated with oral prednisone 0.5 mg/kg/day and dapson 150 mg/day. Over the one-year follow-up the lesions showed regression, with one minimal relapse which resolved after the short course of oral prednisone.
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Gago R, Shum LM, Vilá LM. Right upper quadrant abdominal pain as the initial presentation of polyarteritis nodosa. BMJ Case Rep 2017; 2017:bcr-2016-218019. [PMID: 28228431 DOI: 10.1136/bcr-2016-218019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a necrotising vasculitis that involves medium and small vessels. PAN generally presents with constitutional, cutaneous, neurological, renal and gastrointestinal manifestations. However, PAN initially involving a single organ/system is uncommon. Here, we present a 42-year-old man who was hospitalised because of severe right upper quadrant abdominal pain that started 2 months before. Physical examination was remarkable for right upper quadrant abdominal tenderness. Abdominopelvic CT showed lymphadenopathy but no hepatic, gallbladder, pancreatic, intestinal or renal abnormalities. Abdominal angiography showed multiple small aneurysms located in the jejunal and hepatic arteries characteristic of PAN. He had a prompt and remarkable response to high-dose corticosteroids and oral cyclophosphamide. Our case, together with other reports, suggests that PAN should be considered in patients presenting with right upper abdominal pain. Timely diagnosis and treatment reduce the overall morbidity and mortality of the disease.
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Affiliation(s)
- Ricardo Gago
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Lee Ming Shum
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Luis M Vilá
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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Polyarteritis nodosa and microscopic polyangiitis – The Indian experience. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Cutaneous polyarteritis nodosa, a special form of polyarteritis nodosa (PAN) without systemic involvement, is classified as one of the ANCA-negative vasculitides of small and medium-sized vessels. It is a very rare disease with unknown etiology and occurs more commonly in women over the age of 40. Typical skin lesions are subcutaneous nodules, livedo racemosa, and ulcerations. We report the case of a 46-year-old woman presenting to our outpatient department who reported having very painful ulcerations of the lower legs with unknown origin for 6 months.
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Affiliation(s)
- T M Jansen
- Hautklinik des Universitätsklinikums Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - N-Ph Hoff
- Hautklinik des Universitätsklinikums Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
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Merman E, Rosen C, Ghazarian D, Habeeb AA, Siddha S. Cutaneous Polyarteritis Nodosa Sine Nodosa. J Cutan Med Surg 2014; 18:420-3. [DOI: 10.2310/7750.2014.13165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background and Objective: Cutaneous polyarteritis nodosa, a form of vasculitis affecting the small to medium sized arteries, most commonly presents as tender subcutaneous nodules over the lower legs and feet. Other features include livedo reticularis, skin ulcers and tender indurated plaques. Conclusion: We report a 51-year old woman with a primarily livedo reticularis presentation of cutaneous polyarteritis nodosa without a nodular component.
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Affiliation(s)
- Erica Merman
- From Undergraduate Medicine, University of Toronto; Division of Dermatology, and Department of Pathology, University Health Network Hospitals, Toronto, ON
| | - Cheryl Rosen
- From Undergraduate Medicine, University of Toronto; Division of Dermatology, and Department of Pathology, University Health Network Hospitals, Toronto, ON
| | - Danny Ghazarian
- From Undergraduate Medicine, University of Toronto; Division of Dermatology, and Department of Pathology, University Health Network Hospitals, Toronto, ON
| | - Ayman Al Habeeb
- From Undergraduate Medicine, University of Toronto; Division of Dermatology, and Department of Pathology, University Health Network Hospitals, Toronto, ON
| | - Sanjay Siddha
- From Undergraduate Medicine, University of Toronto; Division of Dermatology, and Department of Pathology, University Health Network Hospitals, Toronto, ON
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Dhaon P, Bansal N, Das SK, Wakhlu A, Tandon V. Cutaneous polyarteritis nodosa presenting with digital gangrene and breast ulcer. Int J Rheum Dis 2013; 16:774-6. [PMID: 24131568 DOI: 10.1111/1756-185x.12187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Pooja Dhaon
- Department of Rheumatology, King George Medical University, Lucknow, India
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