Fig. 6

Intestinal vasculitis and perforation in a 56-year-old male with known ANCA-positive granulomatosis with polyangiitis and long history of immunosuppressive therapy presenting with acute abdominal pain and leukocytosis. Chest X-ray (A) shows two pulmonary nodules projecting over the lower zone of the left hemithorax (black dotted ovals). MRE was obtained. Axial T2-W image (B) reveals multi-focal segmental mural thickening in jejunal loops (thin black arrows). Axial post-contrast T1-W image (C) displays intense mural hyperenhancement (thin white arrows) in the involved segments. Focal intestinal pneumatosis (white dotted ovals) is also evident. Axial T2-W image (D) shows pneumoperitoneum (white arrowheads) at the non-dependent portion of the abdominal cavity, indicating bowel perforation. Coronal T2-W image (E) demonstrates small amount of free fluid (thick white arrows) at the abdominal cavity. Due to acute nature of presentation, the patient subsequently underwent laparotomy. Intraoperative photograph (F) reveals focal bowel necrosis and perforation. No signs of peritonitis were found in the initial examination, more likely due to the immunocompromised status of the patient