Unfortunately the finding of ANCA-negativity leaves cause underdetermined: ANCA-positivity more strongly confirms lack of malignant process, but negativity is clinically ambiguous, and requires further investigation through additional marker tests and via "clinical correlation", meaning mapping pathohistological findings with clinically likely syndromes and disorders that are known to be dependent on those lab markers. Andrew Carlson at Albany Medical College provides the most comprehensive and up to date mapping in this table:
with malignancy as a possible mapping most likely in cases of deep dermal and/or subcutaneous small and/or muscular vessel vasculitis (inflammatory disorders including arthritis, and infections are far more likely causes).
Given the complexity and "fine art" of differential diagnosis, your best bet at this point is to consult with a vasculitis expert: there are two contact chapters of the Vasculitis Foundation in Dallas, and you can contact them online at:
From past experience, it appears that rheumatologists may be the most experienced in this arena, and I have been told that Marian Sackler (214-823-6503) and Richard Leo Stern (214-540-0700) both in Dallas have a vasculitis specialization.
Finally, there are Vasculitis Foundation medical consultants who are willing, time constraints permitting, to consult with other physicians on problem areas, and although currently there are none in Texas, a phone consult and exchange of records may be possible from your med team to one of them, listed here:
From that list I would suggest:
- Stuart Levine, Phillip Seo or David Hellman at the Johns Hopkins Vasculitis Center, or
- Carol Langford Rula Hajj-Ali, at the Center for Vasculitis Care and Research of the Cleveland Clinic
- Peter Merkel or Paul Monach both at the Boston University Vasculiltis Center, or
because they are with the leading vasculitis centers in the country (at Johns Hopkins, Cleveland Clinic, and Boston University). In a consult - often done gratis as a professional courtesy they may be able to suggest what further tests and/or clinical correlations to explore to obtain a more definitive diagnosis.
I will address only one other matter: your INR reading was very low (below 2.0), indicating insufficient anticoagulation (which increases the risk of stroke; whereas a high number (> 3.0) increases the risk of bleeding), where the ideal is between 2.0 and 3.0, towards the middle of that range, so you may want to talk to your physician about that, needing some initiation or adjustment of mild anticoagulant therapy if needed.
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