Mesenteric Vasculitis: A Rare Manifestation of Rheumatoid Arthritis
Dhiren Patel, MD, Ranan Mendelsberg, MD, Shane Yamane, MD, Kevin Taubman, MD.
University of Oklahoma at Tulsa., Tulsa, OK, USA.
Introduction Vasculitis is a rare disease associated with inflammatory response of vessel walls, with or without necrosis and granulomata affecting 20/million a year. Chronic inflammation can weaken or thicken the arterial wall, leading to aneurysm, stenosis, and occlusions. Although vasculitis of the mesenteric arteries is rare, accounting for less than 5 % of all cases of mesenteric ischemia, it can lead to bowel gangrene and death if not immediately recognized and treated.
Case Report 66 y/o Caucasian woman with rheumatoid arthritis and smoking came to ER with acute onset of constant, non-radiating crampy (post prandial) lower abdominal pain with nonbloody emesis and diarrhea for a day. She denied fever, weight loss or prior similar issues. Exam showed typical swan-neck deformities of fingers and moderate tenderness in lower abdomen without guarding or rebound. CT scan revealed multiple areas of high grade stenosis (>70%) with focal distal intimal dissection/thrombosis of superior mesenteric artery without bowel necrosis. Vascular surgery was consulted with concern of acute mesenteric ischemia. Therapeutic anticoagulation was initiated. With worsening pain, she underwent diagnostic laparoscopy, showed mesenteric hematoma and viable small/large bowel. Intraoperative angiogram revealed multiple micro aneurysms in ilio-jejunal mesenteric vascular bed without extravasation. With these findings, along with elevated ESR/CRP, Rheumatology started cyclophosphamide and corticosteroids. She recovered without any complications, discharged home with immunosuppressive medications.
Discussion Mesenteric vasculitis is primarily inflammatory process, corticosteroids with or without immunosuppressants are basis of medical therapy. Rheumatoid vasculitis, the most serious complications of rheumatoid arthritis is a quintessential systemic disease. Extra-articular manifestations develop in 40% of patients, contribute to significant disease-related morbidity and mortality. Among these, systemic rheumatoid vasculitis, characterized by inflammation of mid-size arteries and capillaries, is associated with particularly dire outcome with up to 40% of patients dying within 5 years due to damage from vasculitis and/or consequences of immunosuppressive therapy.
Conclusion Mesenteric vasculitis is a rare manifestation of systemic vasculitis. Most patients have involvement of other vascular territories. Clinical manifestations can range from mild discomfort to life-threatening bleeding or ischemia. Patients with vasculitis who present with abdominal pain and weight loss should be investigated for mesenteric ischemia. Medical therapy is the first line of treatment. Open surgical and/or endovascular reconstruction is indicated in patients who fail medical therapy or have life-threatening bowel ischemia.
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