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Magnetic resonance imaging. A: Axial short-TI inversion recovery (lower legs). B: Coronal T1 (testicles).
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Enhanced magnetic resonance imaging revealed a testicular tumor-like lesion and a slight contrast enhancement in the left anterior and posterior tibial muscles (Fig. 1).
Histopathology of the anterior tibial muscle. Hematoxylin and Eosin stainingx200. The black arrow indicates fibrinoid necrosis of small arteries with histiocytes and neutrophil infiltration around the blood vessels.
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A biopsy of a skin sample taken from the left lower leg revealed fibrinoid necrosis of medium- and small-sized blood vessels and histiocyte and neutrophil infiltration around the blood vessels, indicative of PAN (Fig. 2).
Histopathology of the right testicle. Hematoxylin and Eosin stainingx100. The black arrow indicates fibrinoid necrosis of the small arteries with histiocytes and neutrophil infiltration around blood vessels.
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The results of a surgical biopsy of the right testis also indicated PAN (Fig. 3).
Clinical course. PSL: prednisolone, IFX: infliximab, RTX: rituximab, MTX: methotrexate, CY: cyclophosphamide, TAC: tacrolimus
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Next, a treatment combination of CY, RTX, and tacrolimus (TAC) was initiated, but these immunosuppressive treatments were also ineffective (Fig. 4).