Vasculitis Quiz

A 77-year-old Caucasian female presents to her physician due to a 2 week left-sided headache that is deep, dull, and constant. She has been feeling generally unwell for the past few months with fatigue, malaise, and an unplanned 12 pound weight loss. She thinks she’s had occasional fevers but does not have a thermometer.

Vital signs: Temperature: 99.8 F; HR: 92 /min; RR: 12/min; BP: 124/85 mmHg; SpO2: 96% on room air.

On physical examination the left temple and a structure over the left zygomatic arch are tender. The remainder of the exam is non-contributory. Laboratory testing shows an ESR of 102 mm/hour. An emergency biopsy is performed and the patient is started on a treatment to prevent arterial occlusion. Where does the artery that is causing the patient’s symptoms branch from?

A 26-year-old female presents to her physician because she has started getting pain in her right arm when she plays tennis. She has been feeling increasingly unwell for the past several months with an unplanned weight loss of 10-15 pounds. She has a low grade fever in the evenings. She is experiencing vague aches in her joints and muscles.

Vital signs: Temperature: 99.9 F; HR: 88 /min; RR: 16 /min;  SpO2: 98% on room air.

Physical examination: There is a bruit in the right subclavian fossa. There is no palpable radial pulse in the right arm. The skin and musculature of the right forearm and hand appears normal.

• Brachial BP (left): 124/83 mmHg
• Brachial BP (right): 91/43 mmHg

Laboratory testing

• ESR: 91 mm/hour

Management of the most likely diagnosis would likely include

A mother brings her 4-year-old son to the pediatrician because he has had a high fever for the past 5 days. He has been previously well. He started in a new daycare 4 weeks ago.

Vital signs: Temperature: 102.4 F; HR: 98 /min; RR: 18 /min, SpO2: 98% on room air.

Physical examination: There is conjunctivitis of both eyes without discharge. Lips and tongue are red in color. There is a non-descript rash over the legs and buttocks. There is a 1.4 cm freely mobile lymph node in the neck. The skin of the hands and feet are tender to palpation and mildly swollen.

The next best step in patient management is

A 72-year-old female presents to her physician because she has developed painful sinusitis with bloody nasal discharge over the past several weeks. She has been feeling quite unwell for 2-3 months with fatigue, malaise and a low grade fever in the evening. She has intermittent chest pain and sometimes coughs up blood.

Past medical history is non-contributory. The patient was a school teacher with travel only in the US. She is a non-smoker and only drinks occasionally.

Vital signs: Temperature: 100.1 F; BP: 143/92 mmHg; HR: 88 /min; RR: 24 /min; SpO2: 94% on room air.

Physical examination: Scattered crackles over both lung fields.

Laboratory testing:

• Urinalysis:
  • hemoglobin: 4+
  • protein: 3+
  • leukocyte esterase: negative
  • nitrites: negative
  • sediment: dysmorphic RBCs with occasional red blood cell casts

The test most likely to establish the diagnosis is

A 6-year-old boy is brought to the clinic by his mother because he has developed a rash on his legs and buttocks, represented in the image below. The mother notes that the child is experiencing joint pain, and has red urine. He has otherwise been well but for a cold a few weeks ago. He has recently started kindergarten but there have not been any changes in diet, medication, hygiene habits, or environmental exposures.

Vital signs: normal

Physical examination: the skin lesions are palpable. The remainder of the examination is non-contributory.

Urinalysis:

• Hemoglobin: 3+
• Protein: 3+
• Leukocyte esterase: negative
• Nitrites: negative
• Sediment: numerous red blood cells, no casts seen

The most likely diagnosis could best be established by