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Editor's Correspondence
December 13, 2004

Herod the Great and Polyarteritis Nodosa

Arch Intern Med. 2004;164(22):2500-2509. doi:10.1001/archinte.164.22.2508-a

I read with great interest the article by Hirschmann et al,1 “Death of an Arabian Jew.” With the use of Occam’s razor, I propose that the differential diagnosis of Herod the Great’s terminal illness should include polyarteritis nodosa (PAN). Polyarteritis nodosa is a systemic necrotizing vasculitis that classically affects the small- and medium-sized muscular arteries. Clinical features include both systemic symptoms (fever and fatigue) and symptoms of end-organ damage (gastrointestinal tract, kidneys, nerves, and testicles). Mesenteric arteritis of PAN may have been the cause of his abdominal pain and bowel ulceration. Polyarteritis nodosa may be mistaken for inflammatory bowel disease, and if present, bowel infarction, hemorrhage, and perforation can be fatal.2 Historians describe Herod as suffering from testicular gangrene. Polyartertis nodosa can manifest as a necrotizing vasculitis of the testicular arterioles causing pain and swelling of the testis, epididymis, spermatic cord, and eventually testicular ischemia. If present, testicular biopsy is the diagnostic test of choice.3