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A 43-year-old male presents to your office complaining of weakness in the right hand for 2 days. He reports that he had been in excellent health until 2 months ago, when he was diagnosed with hypertension. Since that diagnosis, he has lost 20 lb unintentionally and complains of frequent headaches and abdominal pain that is worse after eating. He previously was an injection drug user but now is maintained on methadone. His only medications are hydrochlorothiazide 25 mg/d, methadone 70 mg/d, and lisinopril 5 mg/d. On physical examination, the patient appears well developed and without distress. Blood pressure is 148/94. He is not tachycardic. The examination is otherwise notable only for the inability to extend the right wrist and fingers against gravity. Laboratory studies show an erythrocyte sedimentation rate (ESR) of 88 mm/h, an aspartate aminotransferase (AST) of 154 IU/L, and an alanine aminotransferase (ALT) of 176 IU/L. Which of the following tests is most useful in establishing a diagnosis?

A. Hepatitis B surface antigen
B. Hepatitis C viral load
C. Anticytoplasmic neutrophil antibodies
D. Mesenteric angiography
E. Radial nerve biopsy
 

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This patient mostly probably suffers from polyarteritis nodosa (PAN).

The neurological symptoms found in this man's right hand are most probably due to mononeuritis multiplex, which is typically manifested in the context of PAN.

Another characteristic finding of PAN is HBV seropositivity in 30% of patients, and this specific patient has many indications of HBV seropositivity (former IVDU, elevated transaminases).

Although PAN is a type of autoimmune arteritis, ANCA is not typically positive. On the contrary, weight loss, elevated ESR and diastolic hypertension contribute to the diagnosis of PAN.

To the question now... Although positive HBV serology and mesenteric angiography (visceral arteries are typically involved in PAN, showing constrictions and dilations) would be essential for classification purposes, these may well be negative, depending on the stage of the disease. In any case, tissue biopsy is the gold standard for establishing the diagnosis.

So yes, after this mini-essay, I would agree with Dr. mosallam.
 

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This patient mostly probably suffers from polyarteritis nodosa (PAN).

The neurological symptoms found in this man's right hand are most probably due to mononeuritis multiplex, which is typically manifested in the context of PAN.

Another characteristic finding of PAN is HBV seropositivity in 30% of patients, and this specific patient has many indications of HBV seropositivity (former IVDU, elevated transaminases).

Although PAN is a type of autoimmune arteritis, ANCA is not typically positive. On the contrary, weight loss, elevated ESR and diastolic hypertension contribute to the diagnosis of PAN.

To the question now... Although positive HBV serology and mesenteric angiography (visceral arteries are typically involved in PAN, showing constrictions and dilations) would be essential for classification purposes, these may well be negative, depending on the stage of the disease. In any case, tissue biopsy is the gold standard for establishing the diagnosis.

So yes, after this mini-essay, I would agree with Dr. mosallam.
The biopsy is performed to evaluate possible vasculitis in the involved nerve.
 
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