Learning objectives
Present an unusual case of polyarteritis nodosa (PAN) presenting with spontaneous retroperitoneal haemorrhage in a patient with widespread vascular abnormalities
Review anatomical variants of abdominal vasculature
Outline clinical, biochemical and radiographic features distinguishing PAN from differentials
Background
Spontaneous retroperitoneal haemorrhage is an uncommon but life-threatening pathology for which arterial disease is a major cause1.
Arteriopathies including atherosclerosis and vasculitides1 can lead to aneurysmal and friable vessels prone to rupture.
PAN is a rare, often idiopathic, small-to-medium-vessel vasculitis typically affecting the skin, kidneys and gastrointestinal tract of middle-aged patients. Features include arterial stenosis, aneurysms, dissections and rupture, as well as raised inflammatory markers and end-organ dysfunction due to ischaemia2,3.
PAN has several differentials in the setting of retroperitoneal haemorrhage. Sutton-Kadir syndrome involves coeliac...
Imaging findings OR Procedure details
Triphasic computed tomography angiography (CTA) demonstrated active retroperitoneal haemorrhage adjacent to the second part of the duodenum. Sutton-Kadir syndrome was initially considered but immediately discounted when the coeliac axis was found to be patent and supplying only the left gastric and splenic arteries, with the common hepatic artery arising from the superior mesenteric artery (SMA) (figure 3).
SMA angiography (figure 1) showed widespread arterial calibre irregularity consistent with arteriopathy, with a mid-jejunal branch and right colic branches being notable examples.
Right renal artery injected with...
Conclusion
This case illustrates clinical, biochemical and radiographic features which can help distinguish PAN from other differentials before subjecting patients to immunosuppression.
References
Davies GA, Lazo-Langner A, Shkrum M, Minuk L. Spontaneous retroperitoneal hemorrhage in a patient with prolymphocytic transformation of chronic lymphocytic leukemia. Case Rep Hematol. 2013;2013:802376.
Howard T, Ahmad K, Swanson JA, Misra S. Polyarteritis Nodosa. Techniques in Vascular & Interventional Radiology. 2014;17(4):247-51.
De Virgilio A, Greco A, Magliulo G, Gallo A, Ruoppolo G, Conte M, et al. Polyarteritis nodosa: A contemporary overview. Autoimmunity Reviews. 2016;15(6):564-70.
Sutton D, Lawton G. Coeliac stenosis or occlusion with aneurysm of the collateral supply. Clin Radiol. 1973;24(1):49-53.
Kadir S, Athanasoulis...