Unusual pulmonary manifestations in hepatitis B associated polyarteritis nodosa

A young male recently diagnosed as a case of hepatitis B related chronic liver disease and portal hypertension presented with fever, shortness of breath and hemoptysis for the last one month. Chest and abdomen imaging revealed left main pulmonary artery thrombosis with evidence of nodular infiltrates in the right lung,collapse of the left lung (due to profuse pulmonary hemorrhage) and splenic infarcts. Bronchoscopy revealed nodular lesions in left main bronchus with cut-off. Routine anti-microbial screens were all negative. Serum C1q level was raised suggesting likely presence of circulating immune-complexes. As per American College of Rheumatology criteria the patient was labeled as a case of PAN with supportive endobronchial biopsy result. The patient showed dramatic improvement to immunosuppressants and pulmonary lesions showed near resolution. It is thus important to consider PAN as a possible cause of pulmonary manifestations in relation with HBV infection.