toes of the left foot. Examination revealed palpable peripheral pulses, normal ankle-brachial index, active synovitis in 24/28 joints, and sensorimotor deficits with weakness and absent ankle reflex. Laboratory evaluation showed anaemia, thrombocytosis, markedly elevated ESR and CRP, and high RF (288 U/mL) and ACPA (>300 U/mL). ANA and ANCA were negative. CT angiogram ruled out peripheral arterial occlusion, and echocardiography excluded cardiac emboli. Nerve conduction study demonstrated sensorimotor axonal neuropathy. Sural nerve biopsy confirmed vasculitis with axonal damage and perivascular inflammation. A diagnosis of rheumatoid vasculitis was made. Treatment with high-dose intravenous methylprednisolone, followed by oral prednisolone, rituximab, and methotrexate, led to rapid control of joint inflammation and halting of gangrene progression. At 6-month follow-up, the patient was asymptomatic on methotrexate 25 mg/week with steroids tapered off, and no further vascular events. This case highlights that RV may rarely occur early in seropositive RA with poorly controlled disease. Prompt recognition, biopsy confirmation, and aggressive immunosuppression are crucial for favourable outcomes.
Agarawal et al. (Sun,) studied this question.