POLYARTERITIS NODOSA PRESENTING AS AN ACUTE CEREBROVASCULAR ACCIDENT IN A YOUNG MALE. P.J. Bennett 1 , J.J. Yium 1 , M. Panda 1 ; 1 University of Tennesee -Chattanooga, Chattanooga, TN LEARNING OBJECTIVES: To understand the differential diagnosis of CVA in young patients. To recognize clinical features and proper diagnosis of polyarteritis nodosa (PAN) CASE INFORMATION: A 24-year-old black male with a questionable history of multiple sclerosis presented to the ER with acute onset of right-sided weakness, slurred speech and dysphagia. The patient denied any visual symptoms, headache, fevers or recent illnesses. On exam the patient was afebrile, pulse 60 beats per minute, and BP 180/128mm/Hg, neck was supple without bruits, and a 2/6 systolic murmur was noted at the apex. No skin lesions were noted. On neurologic exam the patient had dysarthria, right facial droop and right hemiplegia. Routine lab work was unremarkable with a normal CBC, metabolic panel and sedimentation rate. Urinalysis revealed 2+ proteinuria with benign sediment. LP revealed no oligocional bands. An MRI of the brain revealed a recent deep left-sided infarct involving the internal capsule as well as a small aneurysm of a temporal branch of the right middle cerebral artery. Hypercoaguable work up was negative, p-ANCA was negative but myeloperoxidase antibody was positive. Echocardiogram revealed mild left ventricular hypertrophy with normal LV function. Cerebral and renal angiography revealed innumerable aneurysms involving almost all branches of medium-sized arteries. A biopsy of the sural nerve with accompanying vasculature confirmed the diagnosis of PAN. The patient was treated with steroids, monthly pulse dose Cytoxan, and aggressive physical therapy. Nine months later he shows marked improvement and no further neurologic insults. DISCUSSION: PAN is a systemic vasculitis involving small and medium sized arteries and is more common in middle-aged men. Any organ can be affected but skin, peripheral nerves, joints, intestinal tract and kidneys are most commonly involved. The onset of disease can be abrupt or gradual and usually involves symptoms such as fever, malaise, palpable purpura, infarctive ulcers, joint pain and livedo reticularis, although multiple mononeuropathies are the most typical neurologic manifestation. The sedimentation rate is usually elevated but, as in our case, can be completely normal. Antibody to hepatitis B surface antigen can be positive. Tissue biopsy confirms the diagnosis. Untreated the 5 year mortality rate is greater than 85%. High dose steroid therapy has improved the five-year mortality to 30 ± 45% and the addition of immunosuppressive has reduced relapses. Plasmapheresis offers no additional advantages. Treatment of any associated viral illness (hepatitis, HIV) should be part of the initial therapy.