Summary
Definition
History and exam
Key diagnostic factors
- age 40 to 60 years
- fever
- weight loss
- myalgia or arthralgia
- mononeuritis multiplex
- paraesthesia
- muscle tenderness
- abdominal pain
- skin manifestations
- diastolic blood pressure >90 mmHg
- history of blood transfusion predating introduction of routine HBV screening
- previous or current intravenous drug abuse
- recent hepatitis B virus (HBV) infection
- testicular pain
Other diagnostic factors
- male sex
- hairy cell leukaemia
- seizure
- upper motor neuron weakness
- gastrointestinal (GI) bleeding
- peritonitis
- monocular blindness
- chest pain
- congestive cardiac failure
- tender breast lumps
Risk factors
- hepatitis B virus (HBV) infection
- age 40 to 60 years
- hairy cell leukaemia
- history of blood transfusion predating introduction of routine HBV screening
- hepatitis C virus (HCV) infection
- male sex
Diagnostic investigations
1st investigations to order
- CRP
- erythrocyte sedimentation rate (ESR)
- FBC
- complement
- serum creatinine
- midstream urine analysis
- liver function tests
- HBV serology
- hepatitis C virus (HCV) serology
- cryoglobulins
- blood culture
- creatine kinase
- anti-neutrophil cytoplasmic antibodies (ANCA)
- antinuclear antibodies (ANA)
- anti-double-stranded DNA antibodies (anti-dsDNA)
- rheumatoid factor
- antibodies to cyclic citrullinated peptides (anti-CCP antibodies)
- lupus anticoagulant
- immunoglobulin G antiphospholipid antibodies
- B2 glycoprotein
- fibrinogen
- conventional digital subtraction angiography
- echocardiography
Investigations to consider
- magnetic resonance angiography (MRA)
- CT angiography
- biopsy of affected tissue
- HIV serology
- genetic test for adenosine deaminase 2 (ADA2) deficiency
Treatment algorithm
non-HBV-related PAN
HBV-related PAN
relapse of disease
Contributors
Authors
Ravi Suppiah, MBChB, PGDipSportMed, MD, FRACP
Consultant Rheumatologist
Auckland and Counties Manukau District Health Boards
Auckland
New Zealand
Disclosures
RS declares that he has no competing interests.
Joanna Robson, MBBS, PhD, MRCP
Rheumatology Registrar
Nuffield Orthopaedic Centre
Oxford
UK
Disclosures
JR declares that she has no competing interests.
Raashid Luqmani, DM, FRCP, FRCP(E)
Professor of Rheumatology
NIHR Musculoskeletal Biomedical Research Unit
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science
University of Oxford
Oxford
UK
Disclosures
RL is an author of a number of references cited in this topic.
Acknowledgements
Dr Ravi Suppiah, Dr Joanna Robson and Dr Raashid Luqmani would like to gratefully acknowledge Dr Loic Guillevin, the previous contributor to this topic. LG is an author of a number of references cited in this topic.
Peer reviewers
Alan Bridges, MD
Professor and Vice Chair
Department of Medicine
University of Wisconsin Hospital
Madison
WI
Disclosures
AB declares that he has no competing interests.
Richard Watts, MA, DM, FRCP
Consultant Rheumatologist
Ipswich Hospital
Ipswich
UK
Disclosures
RW has received fees for consulting from Roche Pharmaceuticals, manufacturer of rituximab. His department has received financial support from Wyeth Pharmaceuticals, manufacturer of etanercept, and from Schering-Plough, manufacturer of infliximab. RW is an author of a number of references cited in this topic.
Ellen C. Ebert, MD
Professor of Medicine
Department of Medicine
UMDNJ-Robert Wood Johnson Medical School
New Brunswick
NJ
Disclosures
ECE declares that she has no competing interests.
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