Case Presentation: A 69-year-old male with a complex medical history including coronary artery disease, abdominal aortic aneurysm, and polyarthralgia was hospitalized for treatment of lower extremity necrotizing fasciitis and refractory ulcers. During hospitalization, the patient developed intermittent melena. Upper endoscopy was unremarkable. Contrast-enhanced CT revealed biliary dilation with evidence of blood in the biliary system and multiple new hepatic lesions suggestive of aneurysms. Emergency angiography confirmed multiple hepatic artery aneurysms, with three large aneurysms in the right lobe. It was suspected that bleeding into the biliary tract was caused by the rupture of a giant aneurysm into the bile duct. Urgent catheter coil embolization was performed, successfully stopping further melena. The patient’s history included various vascular lesions, hypertension, polyarthralgia, fever, and weight loss. Notably, previous steroid treatment for polyarthralgia had shown unexpected improvement in pressure ulcers. Given this clinical picture and the discovery of hepatic aneurysms, a diagnosis of probable Polyarteritis nodosa (PAN) was made. Steroid therapy was initiated and adjusted accordingly.
Discussion: PAN is a systemic necrotizing vasculitis affecting medium-sized arteries, often presenting with nonspecific symptoms that can delay diagnosis. We report a case where rupture of a hepatic artery aneurysm into the bile duct led to the diagnosis of PAN.This case highlights the diagnostic challenges of PAN and the importance of considering systemic vasculitis in patients with multisystem involvement. The hepatic artery aneurysm rupture served as a crucial diagnostic clue. It also demonstrates the effectiveness of endovascular techniques in managing acute complications of PAN.
Conclusions: Clinicians should maintain a high index of suspicion for PAN in patients with diverse vascular manifestations. Prompt recognition and management of life-threatening complications, such as aneurysm rupture, are crucial in improving outcomes in these complex cases.