Necrotizing vasculitis as the initial manifestation of rheumatoid arthritis

A 64-year-old Black woman presented with high titer serum rheumatoid factor (RF), pelvic girdle weakness, sensory mononeuropathy, pulmonary fibrosis, and muscle histologic evidence of small artery necrotizing vasculitis. High dose corticosteroid therapy was followed by clinical improvement and reduction in serum RF titer. Four years later, and 9 months after discontinuance of corticosteroids, she developed an inflammatory polyarthritis, recurrent muscle weakness, and left foot drop, concomitantly with circulating immune complexes and extremely high titer serum RF. Necrotizing vasculitis is a distinctly rare presenting manifestation of rheumatoid disease.