ESSENTIALS OF DIAGNOSIS
Medium-sized arteries are affected.
Clinical findings depend on the arteries involved; lungs are spared.
Common features include fever, abdominal pain, extremity pain, livedo reticularis, mononeuritis multiplex.
Kidney involvement causes renin-mediated hypertension.
Anemia and elevated acute-phase reactants (ESR or CRP or both).
Associated with hepatitis B (10% of cases).
Polyarteritis nodosa is a necrotizing arteritis of medium-sized vessels that has a predilection for involving the skin, peripheral nerves, mesenteric vessels (including renal arteries), heart, and brain but spares the lungs. Polyarteritis nodosa is relatively rare, with a prevalence of about 30 per 1 million people. Approximately 10% of cases of polyarteritis nodosa are caused by hepatitis B. Most cases of hepatitis B–associated disease occur within 6 months of hepatitis B infection. Mutations in the gene for adenosine deaminase 2 have been identified in early-onset familial polyarteritis.
The clinical onset is usually insidious, with fever, malaise, weight loss, and other symptoms developing over weeks to months. Pain in the extremities is often a prominent early feature caused by arthralgia, myalgia (particularly affecting the calves), or neuropathy. The combination of mononeuritis multiplex (with the most common finding being foot-drop) and features of a systemic illness is one of the earliest specific clues to the presence of an underlying vasculitis. Polyarteritis nodosa is among the forms of vasculitis most commonly associated with vasculitic neuropathy.
In polyarteritis nodosa, the typical skin findings—livedo reticularis (eFigure 20–27), subcutaneous nodules, and skin ulcers—reflect the involvement of deeper, medium-sized blood vessels. Digital gangrene is common. The most common cutaneous presentation is lower extremity ulcerations, usually occurring near the malleoli. Involvement of the renal arteries leads to a renin-mediated hypertension (much less characteristic of vasculitides involving smaller blood vessels). For unclear reasons, classic polyarteritis nodosa seldom (if ever) involves the lung, with the occasional exception of the bronchial arteries.
Livedo reticularis as a manifestation of antiphospholipid antibody syndrome. (Used, with permission, from Imboden JB et al. Current Diagnosis & Treatment: Rheumatology, 3e. McGraw-Hill, 2013.)
Abdominal pain—particularly diffuse periumbilical pain precipitated by eating—is common but often difficult to attribute to mesenteric vasculitis in the early stages. Nausea and vomiting are common symptoms. Infarction compromises the function of major viscera and may lead to acalculous cholecystitis or appendicitis. Some patients present dramatically with an acute abdomen caused by mesenteric vasculitis and gut perforation or with hypotension resulting from rupture of a microaneurysm in the liver, kidney, or bowel.
Newly acquired hypertension from renin-mediated kidney disease frequently occurs. Subclinical cardiac involvement is common in polyarteritis nodosa, and overt cardiac dysfunction occasionally occurs (eg, myocardial infarction secondary to coronary vasculitis, or myocarditis).