"autoimmune vasculitis" - but no vasculitis. ?

[subbacultcha]

56 y/o supposedly overall healthy woman with history of fibromyalgia type symptoms x2 yrs and 20 yr hx of seeing rheumatologists (don't know for what). Has had episodes of intractable abdominal pain as well as exquisitely painful tips of toes/fingers, which eventually lead to gangrene and amputation multiple times. Clinician says symptoms (including FM issues) improve w/ prednisone and/or methotrexate. Supposedly all "metabolic tests" and various antibody screenings have been negative.

The kicker is that now adult son is developing same issues. I signed out the woman's last toe amputation last week and was pretty stumped because there was literally nothing abnormal. No vascular occlusion/sclerosis, no vasculitis, no skin ulcers, no osteo, etc. etc. Clinician is convinced this is some weird esoteric hereditary autoimmune vasculitis and wants to know what to order.

I'm stumped (no pun intended) and am more suspect of some sort of neuropathy, perhaps? Do the smarty pants of SDN have any brilliant thoughts?

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Münchausen syndrome.

 

[BrainPathology]

56 y/o supposedly overall healthy woman with history of fibromyalgia type symptoms x2 yrs and 20 yr hx of seeing rheumatologists (don't know for what). Has had episodes of intractable abdominal pain as well as exquisitely painful tips of toes/fingers, which eventually lead to gangrene and amputation multiple times. Clinician says symptoms (including FM issues) improve w/ prednisone and/or methotrexate. Supposedly all "metabolic tests" and various antibody screenings have been negative.

The kicker is that now adult son is developing same issues. I signed out the woman's last toe amputation last week and was pretty stumped because there was literally nothing abnormal. No vascular occlusion/sclerosis, no vasculitis, no skin ulcers, no osteo, etc. etc. Clinician is convinced this is some weird esoteric hereditary autoimmune vasculitis and wants to know what to order.

I'm stumped (no pun intended) and am more suspect of some sort of neuropathy, perhaps? Do the smarty pants of SDN have any brilliant thoughts?

I assume that since the patient is seeing a rheumatologist every autoimmune test ever invented has been performed. Given that the patient is on prednisone and methrotrexate biopsies are unlikely to ever find much evidence of vasulitis unless you happen upon some vessels that look like they have old damage of some sort. Has her blood smear been looked at for sickle cells, or some other weird hemoglobinopathy. No real ideas other than that, and I doubt based on the history which must have included huge workups that those will yeild much.

 

[dermpathdoc]

56 y/o supposedly overall healthy woman with history of fibromyalgia type symptoms x2 yrs and 20 yr hx of seeing rheumatologists (don't know for what). Has had episodes of intractable abdominal pain as well as exquisitely painful tips of toes/fingers, which eventually lead to gangrene and amputation multiple times. Clinician says symptoms (including FM issues) improve w/ prednisone and/or methotrexate. Supposedly all "metabolic tests" and various antibody screenings have been negative.

The kicker is that now adult son is developing same issues. I signed out the woman's last toe amputation last week and was pretty stumped because there was literally nothing abnormal. No vascular occlusion/sclerosis, no vasculitis, no skin ulcers, no osteo, etc. etc. Clinician is convinced this is some weird esoteric hereditary autoimmune vasculitis and wants to know what to order.

I'm stumped (no pun intended) and am more suspect of some sort of neuropathy, perhaps? Do the smarty pants of SDN have any brilliant thoughts?

Generally by the time the toe is amputated due to gangrene, the vasculitis is pretty much died out...all you will find at that point is necrosis ie end stage changes. You would need a biopsy on a vessel which is just starting to have issues....