From here, we’re going to move on
to our next organization
of our vasculitides and these
are medium vessel diseases.
Now the medium vessel
vasculitides I want you to,
once again, pay attention to the fact that
does it always have to be
medium blood vessel?
Not necessarily. It could
be a small vessel.
Now I don’t want you to be
contained in that aspect,
but you’re going to be paying attention to
who’s your patient walking through the door?
With polyarteritis nodosa, most
commonly, the patient
is presenting with abdominal pain,
and that’s because the mesenteric arteries
are undergoing inflammation.
In addition, there also might
be issues with hematuria,
and that’s because the renal
blood vessels are being affected.
Also, the patient may have maybe foot drop,
in other words, mononeuritis multiplex.
What’s that mean?
Well if its foot drop, maybe the common
peroneal nerve has been affected
resulting in foot drop or maybe wrist drop
because of radial never issues.
So you have 1 nerve, mononeuritis,
in multiple systems called
Now in terms of, once again, the organs
that you’re paying attention to
mesenteric and the renal.
Could it be elsewhere? Absolutely.
The patient presents with fever
remember, -itis, and wheneve
you see the term –itis,
you can pretty much assume
that with that inflammatory process that
the patient is going to present with fever.
Diagnostic: What are you going to do? Gold
standard is biopsy here as well on necrosis.
The type of inflammation
that you’re going to find
is going to be, what’s known
as, transneural. That’s important.
Look for that description.
Number 2: Mesenteric blood vessel;
thus, the patient presenting with
abdominal pain and maybe
GI bleeding. Correct? Ischemia.
Number 2: On, what’s known
as, your angiography.
Alright? So let’s say that you do
magnetic resonant angiography
I’ll show you a picture coming up—in which,
you’re going to be looking for
Now with those microaneurysms
taking place in the renal region,
no doubt, that there’s a possibility
of hematuria taking place.
Now be careful. Polyarteritis nodosa,
especially with a fever and such,
could be—could be confused
with infectious vasculitis,
but one has nothing to do with the other.
Well, most of these cases,
we’re thinking about steroids,
for organs that are
threatened by the disease.
There is approximately 30%,
I repeat—there’s an approximate 30%
association with hepatitis B.
So if you’re able to properly,
properly manage a patient
with polyarteritis nodosa, then there’s
every possibility that hepatitis B,
and then symptoms and such,
might also subside;
but if there’s hepatitis B then you’re
thinking about drugs to combat this
[Inaudible 00:03:05] steroids, and
plasmapheresis obviously to address
the polyarteritis nodosa. Keep that
in mind. That’s important in terms
Now in this picture that I’m
going to show you in a second,
is the renal blood vessel
of polyarteritis nodosa,
in which, what do you find?
is what the [Inaudible 00:03:28], the flock
of arrows that you’re seeing here
are pointing to little bitty
aneurysms that are taking place
in the picture of angiography.
Thus, the patient presenting
This is for polyarteritis nodosa.
Continue our discussion
of medium vessel disease.
In polyarteritis nodosa,
that’s a patient that is a young
adult, maybe 20’s and such,
polyarteritis nodosa is to
an adult or a young adult,
as Kawasaki is to a child.
So now, some of the symptomology
that you find with Kawasaki,
you could perhaps find
with polyarteritis nodosa;
however, I told you to focus upon
the most common symptoms.
And polyarteritis nodosa, you as a doctor,
he signs that you would see,
obviously would be the abdominal pain or
the patient will complain of abdominal pain.
You might notice GI bleed and hematuria.
In Kawasaki, sure, that
might also occur; however,
in Kawasaki, this is what you’re
going to be paying attention to.
Number 1: That child—that child
must have a fever.
That child, when you observed
the tongue of this child,
it looks like the peel of a strawberry.
So strawberry tongue in pathology
is going to be Kawasaki
whereas strawberry tongue in microbiology
could be something like Scarlet fever.
So now we have fever and now
we have the strawberry tongue.
Next, you’re going to
be looking for the rash,
and that rash is called
desquamation type of rash,
maybe perhaps on the palms and
maybe on the soles of the foot.
That rash is important. That fever is a
must. You cannot even diagnose Kawasaki
without the fever. Remember,
this is of vasculitis.
It’s an anti-endothelial
antibody disease, isn’t it?
Most feared, however, is the fact
that it is the most common acquired
cause of coronary arterial disease
in a child. What does acquired mean?
Not genetic and not congenital.
If that’s the case, then there’s every
possibility in this Kawasaki patient,
that in a child, you’re
looking for that history of
maybe CABG again.
So there’s angioplasty,
maybe stent placing,
and maybe even perhaps CABG.
And also, you’re going to be looking for
that cervical lymphadenopathy.
So things that you’re looking for here,
let me recap—you have the fever;
you have the desquamating rash;
you have the tongue,
the mucous membrane here looks like
the peel of a strawberry, literally.
If you take a look at the eyes,
both bilateral in this child,
they are red injected—so bilateral
And we talked about the coronary
arteries could be affected,
and the child unfortunately, could be
suffering from cardiac disease.
Diagnostically, what are you looking for?
Fever, fever, fever
must be seen more than 5 days, and 4 of
the 5 should be found—here we go:
First beginning with that tongue that I was
talking to you about, mucous membrane,
but in addition to the mucous
membrane of the tongue,
you have the conjunctiva,
The strawberry tongue, which is
the changes in the orad
that rash that I was referring to
known as a desquamating rash
found in the palms and soles,
and cervical lymphadenopathy.
You must find 4 of the 5, and they
will give it to you—they have to,
so that you can diagnose properly
your patient with Kawasaki.
Management: Now this gets
because up until now we’ve been
giving steroids, rightfully so,
and with management of Kawasaki,
[Inaudible 00:07:24] steroids, you
might be thinking aspirin, right?
However, this is a child that has Kawasaki,
and you mean to tell me, this child
is never going to get influenza?
You mean to tell me that the child is
never going to get, maybe chickenpox?
They are viruses. Viruses plus fever,
for a long period of time, could then result
in Reye syndrome—death of the liver.
But, know that if aspirin or,
if you don’t find IVIG
which is IV immunoglobulin, as your
preferred method of treatment,
you must also have aspirin in
the mix. Keep that in mind.
This then reduces, especially the coronary
manifestations, in this child with Kawasaki.
These are the big points of Kawasaki.