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Polyarteritis Nodosa Presenting As Calf Pain

Polyarteritis Nodosa Presenting As Calf Pain

An 18-year-old Hispanic female with no significant medical history presented to our hospital with severe, debilitating pain and weakness in both calves, intermittent fevers over the past three months, drenching night sweats, and new-onset upper extremity bilateral weakness and pain during the previous three weeks.  Her fevers, which had increased from once weekly to twice daily over the past month, usually arrived in the afternoon, with associated chills, frontal headache, nausea, photophobia, phonophobia, and dizziness.  She also reported decreased appetite and a 5 kg weight loss over the prior six months.

The calf pain and weakness had begun four months earlier, concurrent with an upper respiratory infection that resolved within two weeks. This episode was not associated with cough, fever, chills, or night sweats. She had no prior history of respiratory problems. 

She was born in Mexico, has lived in California with her parents and four siblings since the age of 5, and said she has not travelled since. Nor has she gone camping in forest areas or swimming in lakes, although she visited some farm animals five months earlier at a country fair.  She takes care of a dog and a turtle at home, and likes to eat queso fresco made from unpasteurized milk. She denied use of alcohol, tobacco, or illicit drugs, and any sexual activity.  There is no noteworthy family medical history.

By the time she reached our hospital, the patient appeared thin, pale, frail, and younger than her stated age, but in no distress. Physical examination revealed a temperature of 100°F, blood pressure of 114/57 mmHg, pulse of 112 bpm, respiratory rate of 14/min, oxygen saturation of 100% on room air, and a BMI of 17 (below 3rd percentile for her age).  She had no skin rashes, and lymph node, heart, lung, abdominal, and neuromuscular exams were all unremarkable.  

Her upper extremity strength was normal (5/5, although limited by some pain) with full active and passive range of motion.  She had some mild, asymmetric, patchy areas of tenderness in the shoulders, upper arms, and elbows, but no swelling, synovitis, or bony tenderness.  Her lower extremity strength was limited to about 4/5 because of exquisite pain, particularly when squeezing her calves lightly.  She could plantar flex and dorsiflex actively in bed, but she refused to stand or walk due to pain.  Her sensory exam revealed no gross deficits or hyperesthesia. 

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