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Patient Case: Vasculitis

Patient Case: Vasculitis

Discussion

A 45-year-old female presents to a district hospital with a three-month history of fatigue, weight loss, and intermittent fever. She also reports joint pain in her wrists and knees, along with new-onset skin rashes and recurrent nosebleeds. Over the past few weeks, she has developed tingling and weakness in her lower legs, making walking difficult.

On examination, she appears pale and fatigued. There are purpuric skin lesions on her lower limbs, and her blood pressure is elevated. Peripheral pulses are intact but diminished sensation is noted in both feet. Laboratory tests show elevated inflammatory markers (ESR and CRP), anemia, and proteinuria on urinalysis. Further testing reveals positive anti-neutrophil cytoplasmic antibodies (ANCA).

Given the systemic symptoms, skin findings, neurological involvement, and ANCA positivity, a diagnosis of vasculitis is made. The patient is started on corticosteroids and referred to a rheumatologist for immunosuppressive therapy to prevent further organ damage.

Questions
1. What is the most likely diagnosis in this patient?

a) Systemic lupus erythematosus

b) Vasculitis

c) Rheumatoid arthritis

d) Deep vein thrombosis

2. Which of the following findings best supports the diagnosis of vasculitis?

a) Symmetric joint swelling and morning stiffness

b) Purpuric skin lesions, neuropathy, and positive ANCA

c) Isolated elevated blood pressure with no other symptoms

d) Erosive joint damage on X-ray

3. What is the best initial treatment for this patient?

a) Nonsteroidal anti-inflammatory drugs (NSAIDs)

b) High-dose corticosteroids

c) Antibiotics and antihypertensives

d) Physical therapy alone

4. Which of the following complications is most concerning in untreated vasculitis?

a) Permanent organ damage (kidneys, nerves, lungs)

b) Mild joint pain without systemic effects

c) Reversible skin rash with no long-term effects

d) Isolated headache without systemic symptoms

Reveal answers

Answers

1. b) Vasculitis

The patient's systemic symptoms, skin purpura, neuropathy, and ANCA positivity strongly suggest vasculitis, a group of autoimmune disorders that cause inflammation of blood vessels. Other conditions like lupus can have overlapping features but typically present with different autoantibodies (e.g., ANA).

2. b) Purpuric skin lesions, neuropathy, and positive ANCA

Vasculitis commonly presents with systemic inflammation, skin involvement (purpura), nerve damage (mononeuritis multiplex or peripheral neuropathy), and ANCA positivity in certain types like granulomatosis with polyangiitis.

3. b) High-dose corticosteroids

Corticosteroids are the cornerstone of treatment for vasculitis to reduce inflammation and prevent organ damage. Immunosuppressive agents may be added depending on severity. NSAIDs alone are insufficient.

4. a) Permanent organ damage (kidneys, nerves, lungs)

Untreated vasculitis can lead to life-threatening complications, including kidney failure, nerve damage, and lung involvement. Early diagnosis and treatment are crucial to prevent irreversible harm.