Cutaneous Polyarteritis Nodosa in Human Immunodeficiency Virus Infection

Peraire, Joaquim; Vidal, Francesc; Mayayo, Emilio; Torre, Lore Aresti de la; Richart, C

doi:10.1093/rheumatology/32.10.937

Cited by 10 publications

(3 citation statements)

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“…9 Other misdiagnosis of histopathologic features are also actually consistent with thrombophlebitis or phlebitis, but are described as arteritis in nodular vasculitis or polyarteritis nodosa in a dermatology journal 10 or in chapters of dermatopathology textbooks. 11,12 DESIGN AND PURPOSE Four superficial thrombophlebitis cases (Figs.…”

Section: Introductionmentioning

confidence: 99%

The Misdiagnosis of Superficial Thrombophlebitis as Cutaneous Polyarteritis Nodosa: Features of the Internal Elastic Lamina and the Compact Concentric Muscular Layer as Diagnostic Pitfalls

Chen¹

2010

The American Journal of Dermatopathology

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The presence of an internal elastic lamina and a compact concentric muscular layer are the cardinal histologic clues for distinguishing a small muscular artery from small muscular vein. However, the subcutaneous muscular veins in the lower legs usually have thick muscular layers with the proliferation of concentric intimal elastic fibers, which resembles the internal elastic lamina of an artery. Moreover, vertical biopsy specimens of the muscular veins can reveal a compact concentric muscular layer with a round luminal appearance, which also resembles the muscular layer in an artery. As these 2 histologic features are commonly accepted as crucial clues for identifying small to medium-sized muscular arteries, it seems that many cases that are histopathologically proven to be deep dermal or subcutaneous arteritis-including cases documented in numerous dermatology, rheumatology, and dermatopathology-related journals as cutaneous polyarteritis nodosa in Behçet's disease and relapsing polychondritis or granulomatous arteritis in nodular vasculitis-are actually consistent with the features of phlebitis or thrombophlebitis. Cutaneous polyarteritis nodosa and subcutaneous thrombophlebitis are usually found in the lower legs and may present with the same cutaneous manifestation of widespread tender or painful nodular erythema. This also accounts for the difficulty in clinically and histopathologically distinguishing between these 2 disorders. Nevertheless, it is important to make a distinction between arteritis and phlebitis because misdiagnosing subcutaneous thrombophlebitis as polyarteritis nodosa may lead to overtreatment with high doses of systemic steroids. Although the veins in the lower legs may have a compact concentric smooth muscle pattern with a round lumen and the intimal elastic fiber proliferation mimicking the characteristic features of arteries, the elastic fibers in the muscular layer are distributed between the bundled smooth muscle in veins, whereas the elastic fibers are scantly distributed in the medial muscular layer in arteries. A diagnostic assessment that is based on the amount of the elastic fibers in the muscular vessel wall more reliably distinguishes a vein from an artery than does the presence or absence of the internal elastic lamina or a smooth muscle pattern.

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Section: Introductionmentioning

confidence: 99%

The Misdiagnosis of Superficial Thrombophlebitis as Cutaneous Polyarteritis Nodosa: Features of the Internal Elastic Lamina and the Compact Concentric Muscular Layer as Diagnostic Pitfalls

Chen¹

2010

The American Journal of Dermatopathology

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“…Cutaneous polyarteritis nodosa (CPAN) is a rare vasculitis which involves the small‐ and medium‐sized vessels of the dermal–subcutaneous junction. The etiology of CPAN remains unknown, but it has occurred in association with hepatitis B infection, 1 post‐streptococcal infection, 2 tuberculosis, 3 human immunodeficiency virus (HIV) infection, 4 , 5 inflammatory bowel disease, 6 falciparum malaria, diphtheria–tetanus immunization, and drugs. 7 CPAN is a distinct disease that can be distinguished from systemic polyarteritis nodosa (SPAN) by no visceral organ involvement.…”

Section: Discussionmentioning

confidence: 99%

Cutaneous polyarteritis nodosa: a report of a case associated with melioidosis (Burkholderia pseudomallei)

Choonhakarn

Jirarattanapochai

1998

Int J Dermatology

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A 22‐year‐old Thai woman was hospitalized with a 1‐month history of high‐grade fever and slowly progressing multiple erythematous painful nodules on both legs. A history of arthralgia in the knee and ankle joints was presented. She had been treated with acetaminophen and a non‐steroidal anti‐inflammatory drug (NSAID) from a provincial hospital before, but without improvement. She denied the histories of upper respiratory tract infection, jaundice, tuberculosis, and taking any drugs before skin eruption. On physical examination, she had a temperature of 40 °C, a pulse rate of 90 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 110/60 mmHg. She had multiple 1–4 cm erythematous, oval, tender, nodules on the pretibial area of both legs. Some nodules also had fluctuation and hemorrhagic bullae ( Fig. 1). Other physical examinations were normal, except for positive splenic dullness on percussion. 1 Erythematous, subcutaneous nodules with hemorrhagic bleb on both legs Test results from the following laboratory studies were normal; hematocrit, platelet, urinalysis, serum urea nitrogen, creatinine, electrolyte, amylase, liver function test, venereal disease research laboratory (VDRL) test, anti‐streptolysin O, anti‐nuclear antibody, and hepatitis B surface antigen and antibody. Tuberculin test was negative. The chest X‐ray film was normal. Hemoculture and fluid culture from bullae showed no growth of organisms. The leukocyte count was 15.1×109/L, with a differential cell count of neutrophils 73%, lymphocytes 19%, monocytes 7%, and eosinophils 1%. Melioid titer (by indirect hemagglutination test) was 1 : 2560. Ultrasound of the abdomen revealed splenomegaly with multiple, variously sized hypoechoic lesions in the spleen. The liver, gall bladder, pancreas, and kidneys appeared normal. A skin biopsy specimen from the inflammatory nodule on the leg showed perivascular and transmural neutrophilic and lymphocytic infiltration of medium‐sized arteries in the dermal‐subcutaneous junction and fibrinoid necrosis of the vessel walls ( Fig. 2 and 3). 2 Transmural and perivascular neutrophilic and lymphocytic infiltration of medium‐sized artery in dermal–subcutaneous junction (hematoxylin and eosin; original magnification, ×100) Based on the physical examination, laboratory investigations, and histopathology, it was believed that cutaneous polyarteritis nodosa (CPAN), associated with splenic abscess from melioidosis, was the probable diagnosis. Initially, the patient was treated with rest and ibuprofen 1200 mg/day. Although her arthralgia improved slightly, she still had fever and persistent skin lesions. After the results of abdominal ultrasound and melioid titer were reported, we stopped ibuprofen and started treatment as melioidosis. We gave ceftazidime and trimethoprim–sulfamethoxazole. Her fever decreased to normal, and the skin lesions subsided altogether within 10 days. No new skin lesions appeared. The antibodies were then changed to doxycycline and trimethoprim–sulfamethoxazole in o...

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“…De nombreux autres tableaux cliniques de vascularite ont été rapportés comme un purpura vasculaire au cours d'une séroconversion 107 , des vascularites nécrosantes cutanées pures 108,109 , une érythrocyanose des doigts 110 ou une ischémie digitale 65,111 ; ce polymorphisme clinique souligne la difficulté d'affirmer le rôle possible du VIH. Il faut toujours garder à l'esprit la possibilité de vascularites immuno-allergiques, en particulier aux médicaments antiviraux 104,112 .…”

Section: Vascularites Associées Aux Infections Viralesunclassified