| Transcript |
"So, today I'm going to be talking about p-a-n and how it comes to neuro-ophthalmology. So, p-a-n is polyarteritis nodosa and as you can guess it's a multiple vasculitis. And the way it comes to us in ophthalmology is it causes -itis and so it's just like any vasculitis. And it doesn't matter whether that's small or medium or small-to-medium or large vessel vasculitis, the vasculities all are one of the great mimics for ophthalmology because it can produce -itis. And if you just go from the front of the eye all the way back to the brain, we can get keratitis, episcleritis, scleritis. So we got episcleritis, you got scleritis, you got keratitis, or any combination of these. You can be inside the eye. That means it's gonna -it can cause retinal vasculitis or optic neuritis, meningitis, meningoencephalitis. You kind of get the idea that the -itis can be anywhere there's a vessel and thus vasculitis can present to neuro-ophthalmology in any one of these myriad ways. So, in the back of the eye, the optic neuritis and the retinal vasculitis - so the way it comes to me in neuro-op - and so the retinal vasculitis might be an arterial occlusion or cotton wool patches or the roth spot. So, it can, it can look like an arterial occlusion. So, the vasculitis in the back of the eye can take on the appearance of an inflammatory vasculitis in the retina. And so polyarteritis nodosa is one of those strange conditions that you probably have heard about in medical school, but you can't remember quite what the diagnostic criteria are. And so one of the things that I remember is it's like low molecular heparin. So, I'll just give you this mnemonic here -a little more heparin. So you got levido reticularis, which is like liver color because it's a purple, reticular net-like rash and so it looks like, it looks like a net of cutaneous eruptions. We've got the myalgias and tenderness, which are very non-specific. You've got the weight loss, which of course is super non-specific. And so you're kind of getting the idea with p-a-n that a lot of the criteria are kind of vague criteria. It's not at all like lupus or rheumatoid arthritis where they're very defined criteria. And one of the weird things is Hepatitis B is associated infection-wise and another strange thing about the condition is it can mimic other conditions like hypertension, which is so common. So, now you can see how you can easily miss this because things like diffuse myalgia's weight loss, elevated diastolic blood pressure, and hypertension are very, very non-specific findings. One of the interesting things, of course, is the pulmonary arteries are not involved in p-a-n. Pulmonary artery not involved - so that's one of the clues that you might be dealing with something other than vasculitis. When the pulmonary artery is not involved, you should be thinking about p-a-n and, of course, the gold standard is the arteriogram, which is going to show the vasculitis. So, this is the test we're going to be doing in polyarteritis nodosa. So, if we see the vasculitis in the back of the eye, we're going to do an angiogram. That's a fundus fluorescent angiogram. But, if we've got p-a-n in the brain, which is causing neurologic deficits and infarcts, we're going to be doing a catheter angiogram to look for the beating and the other characteristic findings of intracranial vasculitis. Of course, the renal disease - usually that means elevated BUN, creatinine but not like the hematuria that we see in lupus. And then one of the distinctive findings, which is not seen in the other conditions, is epididymitis and testicular pain. So, that's kind of a characteristic feature. So, that's one you definitely should remember because epididymitis is not a typical feature of lupus and rheumatoid arthritis and the other vasculities from ANCA-related things. So, that's kind of a particular thing. And, of course, the way it comes to me is neurologic and the neuro-op findings, as well as the neuropathy, which can be a mono-neuropathy or a poly-neuropathy. So, the neurologic manifestations are going to be related to the vasculitis. And so that means stroke. So, we've got multiple recurrent different vascular distribution stroke and the neuro-op ways that it comes to me are the same ways that it comes to me in the regular eye fanning. So, it's like low molecular weight heparin with an "e" for that epididymitis. That's kind of the mnemonic I've been using for p-a-n. You should be thinking about polyarteritis nodosa whenever we see -itis in the front, the middle, or the back of the eye. But, particularly, retinal vasculitis in combination with the diagnostic criteria, some of which are very nonspecific like myalgia's weight loss, hypertension, pulmonary artery not involved, renal disease, characteristic feature epididymitis. When I'm thinking about p-a-n is when I've got a multiple distribution recurrent stroke- different blood vessels- or if they've got a mono or polyneuropathy in the setting of levido reticularis and the diagnostic test - catheter angiogram." |
