Fatal hemoperitoneum due to rupture of the left gastric artery in a patient with microscopic polyangiitis

Abstract

Microscopic polyangiitis is a vasculitis which primarily affects capillaries, venules or arterioles. Involvement of small and medium-sized arteries may also occur. A 70-year-old Japanese female with a fever and cough was diagnosed with pneumonia and antibiotics were administered. Her symptoms initially improved, but her fever recurred and she experienced malaise and loss of appetite. Her renal function gradually worsened and she was positive for myeloperoxidase antineutrophil cytoplasmic antibodies (MPO-ANCA). She was referred to our hospital on the suspicion of ANCA-associated glomerulonephritis. However, her depressive mental symptoms did not allow her to undergo a renal biopsy. She was clinically diagnosed with ANCA-associated glomerulonephritis, and oral corticosteroids and intravenous methylprednisolone were administered. Her symptoms and renal function were improved, but she died suddenly 15 days after admission. An autopsy disclosed approximately 700 mL bloody ascites. Coagulation adhered to the lesser curvature of the stomach, but the source of hemorrhage could not be detected macroscopically because the gastric mucosa did not show abnormal findings. The histological findings revealed that the left gastric artery showed necrotizing angiitis and rupture. In the kidneys, cellular crescents were found in approximately 10%, fibrous crescents were found in approximately 10%, sclerosis and collapse were found approximately 30% of the glomeruli, and necrotizing angiitis was observed in interlobular arteries and arterioles. From these findings, she was finally diagnosed with microscopic polyangiitis. Microscopic polyangiitis is an extremely rare cause of spontaneous intraperitoneal bleeding, but it must be carefully considered in the differential diagnosis for the appropriate management of such patients.

Death from axillary haemorrhage during haemodialysis in a patient with a history of microscopic polyangiitis

“…It is surprising that axillary haemorrhage related to haemodialysis has not been reported previously, given the spatial proximity of the brachial and axillar vessels. In MPA patients, there are only two reports of spontaneous haemorrhage from the left gastric artery5 and femoral artery 6. In non-MPA cases, three cases have been documented with haemorrhage from the axillary vessels: one that occurred 3 days after axillary catheterisation,7 another with a non-traumatic cause,8 and a third due to non-traumatic shoulder dislocation 9.…”

Expanded spectrum of antineutrophil cytoplasmic antibody–negative vasculitis involving vessels from capillaries to medium‐sized arteries

“…There were no ANCA studies on these patients as the study was conducted in the pre‐ANCA testing era. In 2009, Yahata et al described a patient with clinical diagnosis of MPA on the basis of positive MPO ANCA and kidney dysfunction (no biopsy) (8). The patient was treated with steroids for approximately 2 weeks when she died suddenly from acute hemorrhage.…”

Temporal Artery Involvement in Microscopic Polyangitis

“…One useful point to take into consideration while diagnosing this condition is that more intense inflammation is noted in the branches than in the trunk of the temporal artery, as revealed by pathological examination in our case. Even after making an accurate diagnosis of MPA in the cases presenting with temporal artery lesions, the condition may still be fatal due to injury of large vessels (10). It is also important to note that MPA can cause disorders of various blood vessels.…”