A 54-year-old female presented to a secondary care hospital with right upper quadrant pain, headache, and persistent dysuria after empirical antibiotic treatment for a urinary tract infection (UTI). Her brother had died under the age of 50 from aneurysmal disease associated with Polyarteritis nodosa (PAN). Urinalysis demonstrated erythrocytes, leucocytes, and nitrites. Her CRP was 428mg/L and ESR 102 mm/hr. CT of the abdomen and pelvis showed reduced attenuation within both kidneys, and she was treated as acute bilateral pyelonephritis with IV antibiotics. Her abdominal pain changed, she described a “pop” in her right hypochondrium, and she developed a new visual disturbance, despite normalisation of her inflammatory markers. This warranted a repeat CT scan which showed an occlusion of the left hepatic artery with surrounding inflammation and an 8mm aneurysm proximally. MRI and CT venogram of the head was unremarkable. PAN was diagnosed on remote consultation with a tertiary care hospital. It is a necrosing vasculitis affecting small to medium sized arteries with aneurysmal dilatation. There is no genetic cause known, though familial cases have been described. The patient was started on treatment dose Dalteparin and transferred to a tertiary hospital. Selective embolisation of the hepatic artery aneurysm was not undertaken, but she was treated with glucocorticoids and cyclophosphamide. This case highlights a rare condition presenting similarly to a treatment refractory UTI requiring multidisciplinary patient care and the need for repeat imaging following clinical deterioration/change.
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