A 48-year-old man is admitted to the hospital for recurrent, diffuse abdominal pain. The pain has occurred intermittently for the past 8 months and is worse after eating. Four months ago, the patient underwent emergency laparoscopic surgery with resection of necrotic gallbladder and omental tissue, but he continued to have symptoms. In addition, the patient has experienced intermittent testicular pain and a 13.7-kg (30-lb) weight loss since the onset of symptoms. Medical history is notable for chronic hepatitis B, exercise-induced asthma, acid reflux disease, and renal stones. The patient has a 25-pack-year smoking history and drinks alcohol occasionally. His medications include an albuterol inhaler and omeprazole as needed.
Temperature is 38 C (100.5 F), blood pressure is 180/100 mm Hg, pulse is 78/min, and respirations are 12/min. On examination, the patient appears anxious and diaphoretic. Cardiopulmonary examination is normal. Abdominal palpation elicits diffuse tenderness without any rebound or guarding. Bowel sounds are present. No abdominal masses are palpable, and the stool is negative on guaiac testing. The right testicle appears swollen and tender. There are no skin rashes.
Laboratory results show normal serum chemistry, liver function studies, and complete blood count. Other study results are as follows:
Blood cultures, urinalysis, and urine culture are normal. Chest x-ray and ECG are also normal.
Which of the following is the most likely diagnosis?

Question

A 48-year-old man is admitted to the hospital for recurrent, diffuse abdominal pain.  The pain has occurred intermittently for the past 8 months and is worse after eating.  Four months ago, the patient underwent emergency laparoscopic surgery with resection of necrotic gallbladder and omental tissue, but he continued to have symptoms.  In addition, the patient has experienced intermittent testicular pain and a 13.7-kg (30-lb) weight loss since the onset of symptoms.  Medical history is notable for chronic hepatitis B, exercise-induced asthma, acid reflux disease, and renal stones.  The patient has a 25-pack-year smoking history and drinks alcohol occasionally.  His medications include an albuterol inhaler and omeprazole as needed.
Temperature is 38 C (100.5 F), blood pressure is 180/100 mm Hg, pulse is 78/min, and respirations are 12/min.  On examination, the patient appears anxious and diaphoretic.  Cardiopulmonary examination is normal.  Abdominal palpation elicits diffuse tenderness without any rebound or guarding.  Bowel sounds are present.  No abdominal masses are palpable, and the stool is negative on guaiac testing.  The right testicle appears swollen and tender.  There are no skin rashes.
Laboratory results show normal serum chemistry, liver function studies, and complete blood count.  Other study results are as follows:
 Blood cultures, urinalysis, and urine culture are normal.  Chest x-ray and ECG are also normal.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9727_10b6_853d_d9e63e9a93e1_MD0002_00 This patient has recurrent postprandial abdominal pain suggesting mesenteric ischemia, uncontrolled hypertension, systemic signs and symptoms (ie, fever, weight loss), and elevated inflammatory markers. In light of his negative antineutrophil cytoplasmic antibody (ANCA) test and history of hepatitis B, this presentation is consistent with polyarteritis nodosa (PAN). PAN is a multisystem, necrotizing vasculitis typically involving the mesenteric and renal vessels but sparing the lungs. It is characterized by immune-mediated, small- and medium-size arterial injury with lumenal narrowing, reduced blood flow, and thrombosis, leading to tissue infarction and aneurysm formation. In addition to abdominal (eg, mesenteric ischemia) and gallbladder involvement, this patient has evidence of orchitis (eg, testicular pain, swelling). PAN has been associated with hepatitis B, hepatitis C, and hairy cell leukemia, but the precise etiology is not well understood. There is no specific serologic test for PAN; however, a positive ANCA or antinuclear antibody test suggests an alternate vasculitic process. Tissue biopsy is generally needed for diagnosis. If there is no obvious site for biopsy, the diagnosis can be suggested by angiography showing renal, hepatic, or mesenteric microaneurysms. Treatment usually involves corticosteroids and cyclophosphamide. (Choice A) Essential mixed cryoglobulinemia is associated predominantly with hepatitis C and less commonly with hepatitis B. It usually presents with purpura, weakness, arthralgias, and renal disease. This patient's absence of skin rash makes this diagnosis less likely. (Choice B) Granulomatosis with polyangiitis is characterized by upper and lower airway inflammation and glomerulonephritis. ANCA is positive in >80% of cases. (Choice C) Henoch-Schönlein purpura is an IgA-mediated systemic vasculitis that is primarily seen in children but is less common in adults. Almost all patients have palpable purpura. (Choice D) Like PAN, microscopic polyangiitis causes vasculitis affecting small- and medium-sized arteries. However, glomerulonephritis is present in 80% of cases, pulmonary involvement (eg, hemoptysis) is common, gastrointestinal involvement is uncommon, and the majority of patients have a positive ANCA assay. Educational objective: Polyarteritis nodosa is a small- and medium-vessel vasculitis that presents with multiorgan manifestations (sparing the lungs). It is often associated with hepatitis B. Anti-neutrophil cytoplasmic antibody is negative. Tissue biopsy confirms the diagnosis. If there is no obvious site for biopsy, the diagnosis can be suggested by angiography showing renal, hepatic, or mesenteric microaneurysms. __________ References: Clinical features and outcomes in 348 patients with polyarteritis nodosa: a systematic retrospective study of patients diagnosed between 1963 and 2005 and entered into the French Vasculitis Study Group Database. (http://www.ncbi.nlm.nih.gov/pubmed/20112401) Polyarteritis nodosa. (http://www.ncbi.nlm.nih.gov/pubmed/25399938)

A 48-Year-Old Man Is Admitted to the Hospital for Recurrent