CASE 1

A 42 year old man was admitted with an eight month history of arthritis and lower limb dysesthesia. Examination showed an acutely ill patient with a 39°C fever, oral ulcers, haemorrhagic gingival hyperplasia, bilateral haemorrhagic nasal discharge with crusts, diffuse necrotic purpura, neuritis, and black discoloration of some fingers and toes. The spleen was not palpable. Silent anterior myocardial infarction was diagnosed because of raised MB-CK levels and ST-segment increase with loss of R waves in leads V1,V2,V3 on electrocardiogram.2Antineutrophil cytoplasmic antibodies (c-ANCA) were disclosed in serum and necrotising vasculitis was shown on skin biopsy specimen.3 No antiphospholipid antibody or coagulation protein abnormality could be disclosed. Treatment consisted of intravenous administration of prednisolone, cyclophosphamide, sodium heparinate, diltiazem, dinitrosorbide and enalapril. His short-term course was uneventful. At day 14, the patient …