Rheumatology Q19

A 65-year-old man is evaluated for a 1-month history of progressive malaise, myalgia, a 3.6-kg (8.0-lb) weight loss, and numbness and weakness of the right foot; left testicular pain for 1 week; and a painful rash on his legs for 2 days. He was diagnosed 2 months ago with hypertension, for which he takes hydrochlorothiazide.

On physical examination, temperature is 37.2 °C (99.0 °F), and blood pressure is 165/90 mm Hg. The left testicle is tender. Small necrotic ulcers are noted on the legs. Numbness of the right lateral ankle and calf is noted, as well as weakness of right foot plantar flexion.

Renal angiogram shows microaneurysms of the renal arteries. A deep skin biopsy (deep dermis and subcutis) shows panmural inflammation with necrosis of a medium-sized artery.

Laboratory studies:

Erythrocyte sedimentation rate

100 mm/h

Hemoglobin

10 g/dL (100 g/L)

Leukocyte count

13,000/µL (13 × 109/L)

Platelet count

430,000/µL (430 × 109/L)

Creatinine

1.7 mg/dL (150.3 µmol/L)

ANCA

Negative

Urinalysis

Normal

Which of the following is the most likely diagnosis?

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