SURGEON, MID-HERTS AND WEST HERTS GROUPS OP HOSPITALSTHE diagnosis of periarteritis nodosa has always been somewhat difficult, and even at the present time the condition may be revealed first at autopsy. On occasion it presents itself as an abdominal condition requiring surgical consideration, and Jernstrom and Stasney (1952) have referred to a ' diagnostic dilemma ' in such a case. This paper describes 3 cases of periarteritis nodosa which were of surgical importance. Attention is paid to their clinical aspects in conjunction with the pathological findings, and an attempt is made to clarify the ' dilemma '.
CASE REPORTSCase I.-E. L., a female aged 68 years, who presented in December, 1946, with a six-year history of gastric ulceration. This was confirmed at operation when a partial gastrectomy was performed. The histology of the resected stomach revealed chronic peptic ulcer in active phase.The subsequent history was uneventful until January, 1951, when an acute febrile illness occurred, characterized by cough, haemoptysis, and dyspncea. These symptoms diminished in severity but asthma persisted and anorexia, constipation, and loss of weight were noted. Readmission occurred in April, 1951, after a further haemoptysis.ON EXAMINATION.-Pallor, dyspnea, and loss of weight were evident and chest examination suggested a diffuse bronchopneumonia, confirmed radiologically. The urine contained albumin, pus cells, and casts. The patient had a post-gastrectomy macrocytic hyperchromic anaemia which did not respond to vitamin E,, therapy. The E.S.R. was 55 m m . /~ hr. (Westergren).While in hospital paroxysmal attacks of tachycardia associated with congestive heart failure were observed and death occurred in syncope.AT AuTopsu.-The body of a frail elderly woman weighing 34 kg., with striking pallor of skin and mucous membranes. A healed abdominal surgical scar was present. Fresh blood and blood-clot filled the abdominal cavity. Inconspicuous beaded thickenings were found along branches of the superior mesenteric artery. One of these thickenings was a small aneurysm which had ruptured. The heart was not enlarged, the myocardium was soft, and the wall of the coronary arteries was thickened in places. Bilateral serous pleural effusions with numerous stringlike fibrous adhesions were present on the left side. These were related to scattered areas of chronic pneumonitis in the left lung. Other abnormalities included a small nodular colloid goitre, a solitary cholesterol gall-stone, and partial gastrectomy had been performed.HISTOLOGY.-Periarteritis nodosa was found, affecting the kidneys, lungs, heart, and mesenteric arteries. The mesenteric vessels affected were branches of the superior mesenteric artery of a size range 0.1-0.3 cm. One vessel contained recent thrombus. Another showed segmental destruction and replacement by granulation tissue which had subsequently stretched and given rise to a small aneurysm (Fig. 366). The arteries are cuffed with leucocytes.Comment.-Massive spontaneous intraperitonea1 haemorrhage has been rec...
