A Case of Avascular Necrosis of Bone as the Initial Manifestation of Polyarteritis Nodosa

Soo Min Kim; Bo Hyung Park; Yu Jin Kang; Mi Hui Park; Ju Kyoung Song

doi:10.4078/jkra.2009.16.3.232

Journal List > J Korean Rheum Assoc > v.16(3) > 1003677

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Kim, Park, Kang, Park, and Song: A Case of Avascular Necrosis of Bone as the Initial Manifestation of Polyarteritis Nodosa

Original Article

J Korean Rheum Assoc 2009;16(3):232-237.

Published online: 20 September 2009

DOI: https://doi.org/10.4078/jkra.2009.16.3.232

A Case of Avascular Necrosis of Bone as the Initial Manifestation of Polyarteritis Nodosa

Soo Min Kim¹, Bo Hyung Park¹, Yu Jin Kang¹, Mi Hui Park¹, Ju Kyoung Song²

¹Department of Internal Medicine, Daejeon Sun General Hospital, Daejeon, Korea

²Division of Rheumatology, Taejon Choongang General Hospital², Daejeon, Korea

Received 7 May 2009 Revised 22 June 2009 Accepted 24 June 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

We describe a 28-year old man in otherwise apparently good health, in whom pain in his left knee joint caused by avascular necrosis led to a diagnosis of polyarteritis nodosa (PAN). The angiogram showed multiple microaneurysmal and thrombotic lesions, notably in the renal, mesenteric and tibial arteries. A skin biopsy of the upper dermis of the left thigh with an erythematous skin rash showed the infiltration of mononuclear leukocytes in the perivascular area. During hospitalization, he was diagnosed with chronic hepatitis B, and was treated with lamivudine, and corticosteroid, azathioprine to control the PAN. The knee joint pain improved progressively, and the patient could walk normally after several months. This case is an unusual presentation because the initial manifestation of PAN was avascular necrosis.

Keywords: Polyarteritis nodosa, Avascular necrosis

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Fig. 1.

Whole body bone scan showing increased uptake lesion in the left and right upper tibia, indicating osteonecrotic changes.

Fig. 2.

Magnetic resonance imaging of the left knee. The coronal view of the proton image shows an irregular articular margin with bone cortical necrotic changes and diffuse low signal intensity in the upper tibia.

Fig. 3.

Angiography. Renal angiography showing a multiple microaneurysm in the renal artery branches (A). Mesenteric angiography showing a multiple microaneurysm in the mesenteric vessels, mainly jejunal loop (B).

Fig. 4.

Skin biopsy. Infiltration of many inflammatory cells at the perivascular area of the upper dermis (H&E stain ×100).

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