444. Large vessel involvement in antineutrophil cytoplasmic antibodies associated vasculitis-a rare presentation

Presentation of Case: A 50year older man presented with a history of fatigue, loss of appetite, loss of weight, on and off fever for the last six months. He also gave a history of central back pain that used to aggravate in a supine position and relieve bending forward. He had intermittent small joint pains without any swelling or early morning stiffness. He was diagnosed with new-onset diabetes and started on oral hypoglycemic agents prior to visiting us. He has had pain and blackish discoloration of the right fourth, fifth toes, and lateral aspect of sole for 10 days. He did not give any history of sinus pain, recurrent nasal or ear discharge, hearing loss, cough, or shortness of breath. There was neither any history of oral ulcers or excess hair loss or photosensitivity or dry mouth or dry eyes. He did not complain of claudication pain. On examination, he was moderately built and moderately nourished. All peripheral pulses felt with normal rate and rhythm. There was no carotidynia, or bruit felt. The examination also revealed gangrene Right fourth and fifth toe and tender erythematous patches over the lateral border of the sole. His Blood pressure was 140/90mm Hg. Musculoskeletal examination revealed tender PIP, MCP joints. Cardiovascular, respiratory, and abdominal examination was normal. Diagnostic Testing: Blood tests revealed anemia (Hemoglobin- 9.5gm/dl),leucocytosis(12,360)and high ESR(80mm) and CRP132 mg/dl).Liver and renal function tests were normal. Urine examination revealed proteinuria and active sediment (2+albumin,6-8 pus cells .6-8 RBC and granular casts).ANCA by immunofluorescence showed a perinuclear pattern(2+). Rheumatoid factor was positive(26 IU, normal