MEDICAL IMAGES Chorea and Calcifications: Atypical Presentation of Microscopic Polyangiitis Sadaf Iftikhar, MBBS, FCPS From the Department of Neurology, King Edward Medical University/Mayo Hospital, Lahore, Pakistan. A 45-year-old man presented with generalized chorea. He had a history of low-grade fever, cough, and dyspnea for a couple of months. Physical examination revealed no abnormality except choreiform movements. Investigation showed anemia and eosinophilia on blood examination, proteinuria and hematuria on urine examination, deranged renal function, calcified pin-point foci on chest x-ray (Figure 1), and calcifications in both deltoid (Figure 2) and iliopsoas muscles (Figure 3) on the x-rays. Sputum smear and culture for tuberculosis were negative. Perinuclear antineutrophil cytoplasmic antibodies were positive. Brain imaging was normal. Pulse methylprednisolone was given initially, but the chorea responded well to plasmapheresis. The patient died of rapidly progressive renal failure after 3 months of the histologically proven diagnosis of microscopic polyangiitis. Microscopic polyangiitis is a systemic vasculitis characterized by inflammation of small-sized vessels and the presence of circulating antineutrophil cytoplasmic antibodies. It may involve arterioles, capillaries and venules of kidneys, skin, lungs, and brain and is often detected as necrotizing glomerulonephritis and pulmonary capillaritis.1 It affects more men than women and develops around the age of 50 years. The disease is usually FIGURE 1. Chest x-ray showing multiple pinpoint calcified foci in both lungs. FIGURE 3. Pelvis x-ray showing bilateral Iliopsoas calcifications. FIGURE 2. X-ray showing calcifications in right deltoid. Mayo Clin Proc. n July 2018;93(7):961-962 n https://doi.org/10.1016/j.mayocp.2018.05.023 www.mayoclinicproceedings.org n ª 2018 Mayo Foundation for Medical Education and Research 961 MAYO CLINIC PROCEEDINGS treated with glucocorticoids and cyclophosphamide or rituximab for organ-threatening disease. Plasma exchange may be beneficial in selected cases.2 Potential Competing Interests: The author reports no competing interests. 962 Correspondence: Address to Sadaf Iftikhar, MBBS, FCPS, Manzil-e-Waqar, Fatehabad, Near Wahdat Colony, Lahore 54600, Pakistan (sadafdaisy@gmail.com). 1. Chung SA, Seo P. Microscopic polyangiitis. Rheum Dis Clin North Am. 2010;36(3):545-558. 2. Villiger PM, Guillevin L. Microscopic polyangiitis: clinical presentation. Autoimmun Rev. 2010;9(12):812-819. Mayo Clin Proc. n July 2018;93(7):961-962 n https://doi.org/10.1016/j.mayocp.2018.05.023 www.mayoclinicproceedings.org