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Vasculitides
These are often not thought to be rheumatological origin but may present as a skin or even a neurological disorder. Recognition: there are a number of patterns, reflecting the size and type of vessel involved.
- Leukocytoclastic (small red blobs on the legs).
- Livedo reticularis (lacy purple pattern on the legs).
- Gangrene or ischaemia of a digit or a limb.
- Mononeuritis multiplex (dysfunction of more than one nerve in non-contiguous sites).
- Cerebrovascular accident.
- Renal impairment with active urinary sediment.
- Nail fold capillary changes.
Consider drug reactions particularly in patients with what appears to be a leukocytoclastic vasculitis, and if in doubt (the appearance is actually fairly characteristic) then do a skin biopsy. Types of vasculitis of some relevance are:1
Takayasu’s – this is a large vessel vasculitis and should be considered particularly in young women with unexplained hypertension – look carefully for missing pulses and consider vascular imaging for diagnosis. It is (like giant cell artieritis) a large vessel vasculitis and responds to corticosteroids if active (burnt out disease with normal inflammatory markers does not warrant treatment)
Polyarteritis nodosa – A medium vessel vasculitis. Hypertension and missing or reduced pulses. May have livedo reticularis, skin ulceration, and mononeuritis multiplex. May be an associated arthritis. Some response to steroids and cyclophosphamide.
Wegener’s granulomatosis – ANCA (anti-neutrophil cytoplasmic antibody) positive small vessel disease. Upper and lower respiratory symptoms and renal involvement. Consider steroids and cyclophosphamide.
Farrah TE, Basu N, Dweck M, Calcagno C, Fayad ZA, Dhaun N. Advances in Therapies and Imaging for Systemic Vasculitis. Arterioscler Thromb Vasc Biol. 2019 Aug;39(8):1520-1541. doi: 10.1161/ATVBAHA.118.310957. Epub 2019 Jun 13. PMID: 31189432. ↩