Physical examination revealed numbness in the right fingers and toes and vibration loss in the lower legs. He did not have a cough, chest pain, abdominal pain, fever, headaches, visual loss, dry eyes, or dry mouth. His body weight had decreased by 5Р’В kg within 3Р’В months.

On initial presentation, his vital signs were as follows: blood pressure, 102/46Р’В mmHg heart rate, 82 beats per minute respiratory rate, 18 breaths per minute oxygen saturation, 97% and temperature, 36.9Р’В РІВРЉ. The patient had no remarkable family history and was on flunitrazepam and suvorexant for insomnia, which was unrelated to his current condition. Three months later, he was transferred to our hospital for investigation of general fatigue and numbness.

This is the first case which developed hemoperitoneum in remission state of MPA.Р”В¬linical features and laboratory findingsР”Р„ 66-year-old Japanese man was referred to his primary physician with a one-week history of general fatigue and lower extremity hyperesthesia and numbness however, the cause of his symptoms was unclear at that time. Herein, we describe an unusual case of MPA, in which the patient complained of recurrent chest pain of unknown cause while in remission for MPA and eventually developed treatment-resistant severe hypertension, resulting in a fatal peritoneal hemorrhage due to rupture of the inflamed mesenteric artery and posterior reversible encephalopathy syndrome (PRES). Only six cases of MPA associated with hemoperitoneum have been described in the English literature. Hemoperitoneum progresses rapidly with a poor prognosis however, its clinical diagnosis is extremely difficult. Intraabdominal hemorrhage, or hemoperitoneum, is a rare manifestation of MPA. Microscopic polyangiitis (MPA) is categorized as an MPO-ANCA-related AAV and is usually associated with renal dysfunction, pulmonary hemorrhage, interstitial pneumonia, and peripheral nerve dysfunction. Secondary hypertension associated with vasculitis should be carefully managed to prevent hemorrhagic complications and PRES.Р”Р„ntineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a form of necrotizing vasculitis with few or no immune deposits that predominantly affects the small blood vessels (i.e., capillaries, venules, arterioles, and small arteries) and is associated with elevated serum levels of myeloperoxidase-specific ANCA (MPO-ANCA) or proteinase 3-specific ANCA (PR3-ANCA). In cases of MPA with sudden-onset chest or abdominal pain, a ruptured intra-abdominal artery should be considered. An autopsy revealed that the cause of death was hypovolemic shock due to massive intra-abdominal hemorrhage from the ruptured mesenteric artery involved in vasculitis. Despite intensive treatment, the patient died 3Р’В days later. The patientРІР‚в„ўs blood pressure was high despite antihypertensive therapy, and he developed posterior reversible encephalopathy syndrome (PRES). A diagnosis of acute cardiovascular syndrome was suggested however, his cardiac artery was not stenotic. Two months after discharge, he visited the emergency department because of chest pain. His blood pressure was elevated and was controlled by amlodipine treatment. Remission-induction treatment with glucocorticoids and rituximab was initiated, which improved the patientРІР‚в„ўs general condition and renal failure. Renal biopsy revealed crescentic glomerulonephritis with necrotizing vasculitis, which was associated with a high serum titer of MPO-ANCA, leading to a diagnosis of MPA. A 66-year-old man was admitted to our hospital for renal dysfunction, numbness, and weight loss for 3Р’В months. While generally associated with renal dysfunction, MPA can also cause intraabdominal hemorrhage in rare cases. Microscopic polyangiitis (MPA) is a type of necrotizing vasculitis associated with high levels of myeloperoxidase-specific antineutrophil cytoplasmic antibody (MPO-ANCA).

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