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Rheumatoid vasculitis — SCE Rheumatology MCQ

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EasyRheumatoid arthritisRheumatoid vasculitisSCE Rheumatology

A 67-year-old man with a 20-year history of severe erosive, seropositive rheumatoid arthritis and rheumatoid nodules presents with painful black lesions on several fingertips. Examination confirms digital infarction and an asymmetric painful sensorimotor neuropathy consistent with mononeuritis multiplex. His ESR is 78 mm/hour, rheumatoid factor titre is very high and complement levels are low. Urinalysis is normal, serum cryoglobulins are not detected, and he has no upper-airway or pulmonary symptoms or history of a recent vascular procedure. What is the most likely diagnosis?

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Correct answer: B — Rheumatoid vasculitis

The diagnosis is rheumatoid vasculitis. It typically occurs in patients with long-standing, severe, seropositive and often nodular rheumatoid arthritis. Digital infarction and mononeuritis multiplex are characteristic manifestations reflecting cutaneous and peripheral-nerve vascular involvement; a very high rheumatoid factor titre and low complement provide additional support. Cryoglobulinaemic vasculitis can cause neuropathy and hypocomplementaemia, but cryoglobulins are absent. ANCA-associated vasculitis can cause mononeuritis multiplex, but there are no renal, pulmonary or upper-airway features, and the rheumatoid phenotype is much more compelling. Cholesterol embolisation usually follows vascular instrumentation and commonly causes livedo and renal injury. Antiphospholipid syndrome causes thrombotic disease but does not characteristically produce this combination of severe nodular rheumatoid arthritis and vasculitic neuropathy.

Reference: Rheumatoid vasculitis in 2023: Changes and challenges since the biologics era, 2023. https://pubmed.ncbi.nlm.nih.gov/2189161/