Polyarteritis nodosa

Last reviewed: 23 Aug 2023
Last updated: 02 Nov 2022



History and exam

Key diagnostic factors

  • age 40 to 60 years
  • fever
  • weight loss
  • myalgia or arthralgia
  • mononeuritis multiplex
  • paresthesia
  • 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
More key diagnostic factors

Other diagnostic factors

  • male sex
  • hairy cell leukemia
  • seizure
  • upper motor neuron weakness
  • gastrointestinal (GI) bleeding
  • peritonitis
  • monocular blindness
  • chest pain
  • congestive cardiac failure
  • tender breast lumps
Other diagnostic factors

Risk factors

  • hepatitis B virus (HBV) infection
  • age 40 to 60 years
  • hairy cell leukemia
  • history of blood transfusion predating introduction of routine HBV screening
  • hepatitis C virus (HCV) infection
  • male sex
More risk factors

Diagnostic investigations

1st investigations to order

  • CRP
  • erythrocyte sedimentation rate (ESR)
  • CBC
  • complement
  • serum creatinine
  • midstream urine analysis
  • liver function tests
  • hepatitis B virus (HBV) serology
  • hepatitis C virus (HCV) serology
  • cryoglobulins
  • blood culture
  • creatine kinase
  • antineutrophil 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
More 1st investigations to order

Investigations to consider

  • MR angiography (MRA)
  • CT angiography
  • biopsy of affected tissue
  • HIV serology
  • genetic test for adenosine deaminase 2 (ADA2) deficiency
More investigations to consider

Treatment algorithm


non HBV-related PAN

HBV-related PAN


relapse of disease



Ravi Suppiah, MBChB, PGDipSportMed, MD, FRACP

Consultant Rheumatologist

Auckland and Counties Manukau District Health Boards


New Zealand


RS declares that he has no competing interests.

Joanna Robson, MBBS, PhD, MRCP

Rheumatology Registrar

Nuffield Orthopaedic Centre




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




RL is an author of a number of references cited in this topic.


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




AB declares that he has no competing interests.

Richard Watts, MA, DM, FRCP

Consultant Rheumatologist

Ipswich Hospital




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



ECE declares that she has no competing interests.

  • Polyarteritis nodosa images
  • Differentials

    • Granulomatosis with polyangiitis (formerly known as Wegener granulomatosis)
    • Microscopic polyangiitis
    • Churg-Strauss syndrome
    More Differentials
  • Guidelines

    • Guideline for vaccinations in patients with rheumatic and musculoskeletal diseases
    • BSR and BHPR guidelines for the management of adults with ANCA-associated vasculitis
    More Guidelines
  • Patient leaflets

    Pneumonia: do I need a vaccine?

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer