Low-Dose Methotrexate Controls a Severe Form of Polyarteritis Nodosa

A 41-year-old white man presented with a 7-year history of erythematous papules, livedo reticularis, swelling, myalgias, arthralgias, Raynaud phenomenon, and very large, painful and progressive ulcers on the lower part of both legs (Figure 1). A skin biopsy specimen revealed polyarteritis nodosa (PAN) with fibrinoid necrosis of medium-sized vessels. The patient fulfilled 4 of the criteria for PAN (ie, weight loss .4 kg, livedo reticularis, myalgias, and characteristic histological picture). Also, he had an elevated erythrocyte sedimentation rate, leukocyte count (Figure 2), CD3 cell count (pan-T cells) (3.5 3 10/L), CD3CD4 T-cell count (T-helper cells) (2.7 3 10/L), and antinuclear antibody titer (1:640, speckled pattern). Systemic prednisone therapy administered at dosages as high as 100 mg/d had little, if any, effect. The patient’s intense pain could only be controlled with morphine derivatives.