Cardiac computed tomography unmasks cardiac involvement in immune complex vasculitis in a patient with chest pain and shortness of breath

Abstract Background Computed coronary tomography angiography (CCTA) is an important diagnostic tool in patients with suspected acute coronary syndromes (ACS). We present a case of vasculitis and coronary involvement, in which CCTA provided critical insights for both diagnosis and management. Case summary A 54-year-old male patient with a history of arterial hypertension, hyperlipidaemia, chronic hepatitis B, and smoking presented with stable angina and exertional dyspnoea. He reported intermittent fever up to 38.5 °C, and unintentional weight loss over the past 4 months. Physical examination revealed erythematous papules on the arms and palpable purpura on the lower legs, present for 2 weeks. Electrocardiogram and echocardiography were unremarkable, but due to elevated cardiovascular risk and mildly increased troponin levels, coronary artery disease (CAD) was suspected. He therefore underwent CCTA, which demonstrated mild to moderate stenosis of the right coronary artery along with pronounced concentric wall thickening in all three major coronary vessels, raising suspicion for vasculitis. Extensive screening for infectious, autoimmune, and connective tissue diseases was negative. A skin biopsy of the right calf confirmed cutaneous leukocytoclastic vasculitis despite negative serologic markers. The patient was initiated on immunosuppressive therapy with glucocorticoids, resulting in symptomatic improvement and regression of coronary stenoses on follow-up CCTAs. Discussion To our knowledge, this is the first reported case of seronegative immune complex vasculitis with isolated cardiac involvement and no other systemic manifestations. In this case, CCTA not only provided detailed anatomic visualization of the coronaries but also offered precise insights into coronary wall composition, the presence of inflammation, and plaque characteristics.