Rheumatoid vasculitis is a rare and late complication of rheumatoid arthritis, affecting small to medium sized vessels. Inflammation in the vessel wall produces an occlusive vasculopathy with downstream infarction. We present the case of a 70-year-old female with long standing stable RA status post recent COVID-19 vaccination admitted with community acquired Legionnaires disease found to have an incidental renal infarct on chest imaging without a clear etiology. She improved from a respiratory standpoint but then had a fever spike with repeat imaging showing a second renal infarct and CT angiography showing extensive beading with aneurysmal dilation in the bilateral hepatic and renal arteries consistent with vasculitis. Given extensive RA history, there was a high index of suspicion for rheumatoid vasculitis and she was treated with pulse steroids followed by Rituximab with tapering of steroids and clinical recovery. Her presentation is unique given the salient features, extensive multi-vessel disease without localizing symptoms and potential role of Legionella infection or COVID-19 vaccine in immune activation.

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