pANCA Positive Classic Polyarteritis Nodosa

This 62 years old male presented with progressive weakness of upper and lower limbs since 3 months which was subacute, asymmetrical in onset and painful. It began on the right side and went over to the left (Rt UL → Rt LL → Lt UL and LL) but there was no bladder involvement. He had associated low grade fever off and on. He received IV steroids (alternate day dexamethasone injection) followed by transient improvement. There were 6 to 7 episodes of malena and the steroids were stopped. There was decreased urine output since 1 month associated with vomiting, generalized edema and subsequently he lapsed into altered sensorium. He was unable to recognize his relatives and would talk incoherently. There was h/o bronchial asthma since 10 years. There was no history of cranial nerve palsies, headache, seizures or hemiplegia. No h/o cough, expectoration, hematuria, jaundice, joint pains, rash, oral ulcers and photosensitivity. He was a reformed smoker and an occasional alcohol consumer. On examination, he was drowsy, disoriented, afebrile, pulse 86 per minute BP—120/80 mm Hg and respiratory rate was 18/minute. There was pallor, pitting edema, clubbing, b/l basal crepitations, CNS status was E3-4 V5M6 with left LR palsy, right UMN 7th nerve palsy, wasting of b/l intrinsic hand muscles, hypotonia of all four limbs,