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A CASE OF POLYARTERITIS NODOSA.
By B. Barling, M.D., B.S., M.R.C.P., M.R.C.S., Senior Assistant Medical Officer,
St. Mary, Islington, Hospital.
Polyarteritis nodosa is interesting clinically as the symptomatology is so
protean as to simulate other diseases. It is essentially a primary vascular disease,
of unknown etiology, which is heralded by mild fever, sore throat, vague pains in
the limbs and trunk and accompanied by leucocytosis, together with progressive
loss of weight, fatigue and weakness.
The variation of the symptoms and signs depends upon the localisation of the
arteries involved. In one case the cerebral symptoms may predominate, in others
the cardiac, pulmonary or renal. The superficial vessels may also be involved so
that it is possible to ascertain the presence of the nodules on the vessels by
palpation.
G. A. H., aged 16 years, whilst employed as a tricycle messenger was knocked down by a
car. He received some degree of concussion and was sent to hospital the next day. When
admitted, he complained of generalised headache and vomiting. On examination, his condition
was found to be good. He was quite conscious and able to answer questions.
Case history.
Cardio-vascular system: Pulse regular 68. Heart no abnormal physical signs except a
soft systolic bruit over the pulmonary area.
Respiratory and gastro-intestinal systems—no signs of disease.
The examination of the central nervous system revealed a slightly larger left pupil than
right. They both reacted briskly, and the fundi were normal. All reflexes were present and
brisk.
Occupying almost the whole of the vertex of the skull was a large fluctuating cephal
hæmatoma. The skull was X-rayed that day, but no fracture was demonstrable.
He was treated in bed and the hæmatoma steadily became absorbed.
27th April, eighteen days after admission he complained of headache and sore throat, the
temperature shooting up to 104° and the pulse to 118. The fauces were congested and a swab
taken at the time was found to be negative for K.L.B.
By the 29th the temperature had subsided to normal and the throat felt better. Four
days later, 3rd May, the temperature rose to 100° and the pain and congestion of the throat
increased. This was followed by pain on the left side of the neck, with a very tender diffuse
swelling in the posterior triangle low down above the clavicle on that side.
This swelling subsided in ten days, but the throat, although it felt less painful, remained
congested and inflamed. The temperature from the date of the recrudesence of the sore throat
remained up, fluctuating between 103° and 99°, the pulse rate varying between 76 and 108.
30th May.—The fauces were still infected and the cervical glands enlarged, in addition, he
complained of pains across the loins and there was some hæmaturia. The urine contained
albumen and a moist film of the deposit showed large numbers of red blood corpuscles, a
few pus cells and some epithelial cells. Staphylococci and diphtheroids were present in the
Gram film.
He was pale and a little drowsy. The tongue clean and dry and the fauces infected. The
pulse rate had increased to 133, but no bruits were detected in the heart and no abnormal physical
signs were found in the lungs.
On examination of the abdomen, the tip of the spleen could be felt and although the kidneys
were not palpable, they were both very tender. The examination of the central nervous system
revealed only some congestion of the vessels of the fundi.
The report on a blood count made that day was as follows: red blood corpuscles, 4,120,000
per c.mm.; haemoglobin, 72 per cent.; white blood cells, 38,000 per c.mm.; polymorphs
neut., 89 per cent.; eosinophils, 2 per cent.; lymphocytes, 9 per cent.
Red blood corpuscles normal in appearance. As the renal tenderness was mainly right, the
blood count suggested peri-nephritic abscess, but at no time could a mass be demonstrated.
From then onwards the urine contained albumen and blood each day, but there was no
reduction in the quantity of urine passed and on some occasions the urinary excretion actually
reached one hundred ounces in the twenty-four hours. The blood urea was 87 mgm. per 100 c.c.
9th June a baffling symptom presented itself. The right arm became completely paralysed,
with loss of all reflexes. There was weakness of all muscles below the shoulder except the
biceps and coraco-brachialis. Anæsthesia to pin-prick and cotton wool was present along the
ulna border of the forearm from the elbow to the fifth finger. There were no abnormal findings
in the left arm. The abdominal reflexes were all present and active.
The knee jerks and ankle jerks were present and active, and the plantar reflexes flexor.
A lumbar puncture was performed. The pressure of cerebro spinal fluid was 280 mm. of
water. The result of examination of the fluid was: cells, less than 1 per c.mm.; total protein,
.3 per cent.; chlorides, 640 mgm. per cent.; no organisms seen in Gram film; no tubercle
bacilli found; culture, no growth; Lange curve, 2223332000.
The Wassermann and Kahn reactions were negative.
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