Lupus Sometimes Starts As Just a Gut Feeling

October 17, 2014

Nausea and vomiting are the first symptoms of lupus in these three case studies. The consequences of misdiagnosis can be life-threatening.

Sran S,Sran M,Patel N,  and Anand P. Lupus enteritis as an initial presentation of systemic lupus erythematosus. Case Reports in Gastrointestinal Medicine (2014)  2014: 962735. doi: 10.1155/2014/962735.Online Sep 11.

Jia Y, Ortiz A, Mccallum R, et al. Acute pancreatitis as the initial presentation of systemic lupus erythematosus. Case Reports in Gastrointestinal Medicine (2014) 2014: 571493. doi:  10.1155/2014/571493. Online Aug 14.

Mukhopadhyay S, Jana S, Roy MK, et al.Lupus cystitis: An unusual presentation of systemic lupus erythematosus. (2014) Indian Journal of Nephrology 24(5):308-311. doi:10.4103/0971-4065.133010.

These three recent case studies are reminders that nausea, vomiting, and abdominal pain may be the first signs of systemic lupus erythematosus (SLE), sometimes with life-threatening implications. 

Lupus Enteritis

The first study, from the Nassau University Medical Center in East Meadow, New York, desciobes a 34-year-old woman who went to an emergency department after three days of abdominal pain, vomiting, and painful lesions on the skin of her legs.

After diagnosing lupus enteritis, the authors treated her with systemic steroids, and the abdominal pain and skin lesions subsided within a few days. They discharged her on hydroxychloroquine and a tapering dose of steroids.

Histopathology rarely confirms a diagnosis of lupus enteritis, they observe. Diagnosis is based on classical CT findings:

Bowel wall edema with target sign
Mesenteric abnormalities and ascites

Overlooking the diagnosis and delaying treatment may result in bowel ischemia and perforation, they warn.

“Typically, lupus enteritis is steroid-responsive with an overall excellent prognosis and immunosuppressive treatment is reserved for recurrent enteritis or severe SLE cases with multi-organ involvement,” the authors conclude.

Acute Pancreatitis

In the second study, researchers from the Texas Tech University Health Sciences Center in El Paso, describe another woman who presented with abdominal pain and vomiting, this one 23 years old. The diagnosis of at admission was acute pancreatitis. Despite supportive treatment, her condition deteriorated.

Clinical and laboratory criteria pointed to SLE with possible lupus nephritis and mesenteric vasculitis.

After several days of treatment (methylprednisolone, levofloxacin, metronidazole, Bactrim, cyclophosphamide, and mesna), the authors sent her home with tapering doses of prednisone. One month later, a kidney biopsy indicated class III lupus nephritis.

“Systematic lupus erythematosus-related pancreatitis is an exclusive diagnosis that could be made only after ruling out other possible etiologies,” the authors write. It carries an increased mortality risk, they point out, particularly when comorbid with infections, shock, and renal and respiratory insufficiency.

Lupus Cystitis

The third report, from the Institute of Post Graduate Medical Education and Research in Kolkata, India, involves a 20-year-old woman  with recurrent episodes of abdominal pain, vomiting, and constipation diagnosed as having SLE associated with paralytic ileus and chronic interstitial cystitis.

Treatment with intravenous methylprednisolone and cyclophosphamide pulse therapy followed by oral prednisolone and azathioprine brought improvement, but three months later the gastrointestinal symptoms recurred.

Increased proteinuria and a kidney biopsy confirmed a  lupus nephritis. Mycophenolate mofetil resolved the proteinura.

“This condition responds well to combination therapy with corticosteroid and cyclophosphamide,” the authors conclude.