Polyarteritis nodosa with uterine involvement
A 78-year-old woman with a history of hepatitis B and Sjögren syndrome was admitted to a local clinic near her house experiencing prolonged fever and leg pain. After being transferred to our hospital, a complete physical examination revealed leg livedo. She did not notice atypical genital bleeding. Laboratory tests showed high levels of C-reactive protein, a high white blood cell count and a high erythrocyte sedimentation rate. The patient's tumor markers were normal, except for high CA-125. In order to exclude aortitis, focal infection, or malignancy, a whole-body contrast-enhanced multidetector-row computed tomography (MDCT) examination was performed and three-dimensional CT angiography (3-D CTA) was reconstructed. Transaxial images and maximum intensity projection (MIP) of the MDCT showed multiple microaneurysms in the liver (Fig. a and b) and irregularity and ectasia of the celiac and renal arteries (Fig. c). Multiple microaneurysms in the liver and irregularity and ectasia of the renal arteries were seen with 3-D CTA (Fig. d). Transaxial images of the MDCT showed that the patient's uterus was large for her age (Fig. ). In order to rule out endometrial cancer, pelvic MRI was performed. T2-weighted imaging (WI) and diffusion-weighted imaging (DWI) showed the thickness of the endometrium and uterine muscle. T2-WI and DWI (Fig. a and b) also showed high signal intensity in part of the parametrium. However, MRI did not show disarray of the uterus' structure or a tumor. A pathological examination of the endometrium performed to rule out the presence of endometrial cancer showed significant infiltration of neutrophils with no malignancy. Hence, she and her condition were carefully followed.\nBased on physical findings (leg pain, livedo, elevated C-reactive protein, and fever) and the microaneurysms found in her liver by 3-D CTA, systemic polyarteritis nodosa (PAN) was diagnosed and methylprednisolone was administered. Two months later, her fever and leg pain had disappeared. Follow-up whole-body CT with 3-D CTA and pelvic MRI were then performed. Follow-up 3-D CTA showed that the multiple microaneurysms in her liver had completely disappeared, although irregularity and ectasia of the celiac and renal artery had remained (Fig. ). Follow-up pelvic MRI showed that the thickness of both the uterine endometrium and muscle had diminished, and the signal intensity on both DWI and T2-WI in the parametrium had decreased (Fig. ).