BACKGROUNDPolyarteritis nodosa (PAN) is a systemic vasculitis of small and medium-sized arteries. Neurological involvement, mostly peripheral neuropathy, occurs in one fourth of cases. Subarachnoid hemorrhage (SAH), usually due to aneurism rupture, is a rare event in PAN. We herein describe a yet more unusual case of a non-aneurysmal medullary SAH as initial presentation of PAN. CASE REPORTThe patient, a 56-year-old woman, was admitted due to an excruciating dorsolumbar pain. A previous history of hypertension was referred. In hospital, refractory hypertension demanded intensive care for a week. Magnetic resonance image (MRI) disclosed a typical, extensive, medullary SAH. A cranial MRI showed a small focus of SAH in the posterior region. Arteriography demonstrated aneurisms of hepatic, splenic and small-sized renal arteries; no aneurisms were seen in cerebral or medullary arteries. C-reactive protein was raised (8 mg/dL), but no autoantibodies were detected. Given the high possibility of PAN, a combined pulse of methylprednisolone and cyclophosphamide was carried out, with satisfactory outcome. The patient is now on high-dose prednisone, monthly intravenous cyclophosphamide and antihypertensives.
BACKGROUNDBone and joint tuberculosis reaches up to 35% of cases of extrapulmonary tuberculosis (TB), especially in immunosuppressed patients. Skeletal TB most often involves the thoracic spine (Pott's disease), followed by tuberculous arthritis in weight-bearing joints and extraspinal TB osteomyelitis. The sacroiliac joint (SI) is an uncommon site of infection and its diagnosis is often delayed. CASE REPORTA 37-year-old woman, housewife, with no comorbidities, presents with a 6-month progressive inflammatory low back and right gluteal pain. During this time, she used several anti-inflammatory drugs with partial improvement of symptoms and frequent recurrence. Two weeks before admission, she started presenting evening fever and night sweats and was treated with amoxicillinclavulanate for seven days, with no improvement in symptoms. There was a loss of 5 kg throughout the period. She came to the emergency with disabling low back pain, no respiratory, genitourinary or gastrointestinal symptoms. Her physical examination revealed stable vital signs, pain in SI topography, and positive Patrick's and Gaenslen's tests. Laboratory tests were performed showing mild normocytic normochromic anemia, high levels of erythrocyte sedimentation rate and C-reactive protein, negative viral serology. Magnetic resonance imaging (MRI) of sacroiliac joints revealed sacroiliitis with inflammatory and infectious features (Figure 1). A computed tomography (CT) was carried out to guide a biopsy, also showing bone erosions (Figure 2). A chest CT demonstrated a miliary pattern (Figure 3). Joint fluid showed a rapid test (PCR) for Mycobacterium tuberculosis and negative acid-fast bacillus (AFB) test. Mycobacterium tuberculosis culture and IGRA (interferon gamma release assay) were performed with a positive result. Treatment with rifampicin, isoniazid, pyrazinamide and ethambutol were started.
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