Rheumatoid arthritis associated vasculitis: a rare entity; case and review

Abstract

We present a case of a 60-year-old male with known seropositive rheumatoid arthritis and cerebral vasculitis who presented to the emergency room with abrupt onset lower back and abdominal pain. The patient developed peritonitis which led to an abdominal laparotomy where jejunal ischemia, necrosis, and perforation were found, requiring bowel resection. On pathology examination, the patient had mesenteric vessel intramural inflammation indicative of vasculitis. He developed an anastomotic leak on postoperative Day 4 and elected hospice care. A high index of suspicion for mesenteric vasculitis should be considered in patients presenting with abdominal pain in the setting of known rheumatoid arthritis associated vasculitis, especially patients with long-standing rheumatoid arthritis. The high mortality represented by gastrointestinal involvement in rheumatoid arthritis associated vasculitis warrants investigation in high-risk patients, despite its low prevalence. Treatment may consist of high-dose corticosteroids, immunosuppressive agents, biologic therapies that target the underlying autoimmune process, and in severe cases, bowel resection.

Keywords: autoimmune; colorectal surgery; inflammation; intestinal ischemia; mesenteric vasculitis; rheumatoid arthritis; small bowel surgery; vasculitis.

Figure 1

Mesenteric vessels with intramural inflammation.

Figure 2

Mesenteric vessels with intramural inflammation.

Figure 3

Small bowel with full thickness ischemic necrosis.