2540 An Exceptionally Rare Cause of Abdominal Pain: Protein C Deficiency-Induced Mesenteric Panniculitis

Abstract

INTRODUCTION: Mesenteric panniculitis (MP) is a rare benign disorder that affects the intestinal mesentery causing unexplained gastrointestinal complaints. Herein, we present a case of MP-induced by microinfarction due to Protein C deficiency. CASE DESCRIPTION/METHODS: A 46-year-old female patient with a significant medical history of protein C deficiency and recurrent deep vein thrombosis on long term anticoagulation with warfarin presented to the emergency department after a syncopal episode. She suffered from persistent nausea, vomiting, inability to tolerate oral intake, and mild abdominal pain for the last two weeks prior to presentation. Physical examination was mostly unremarkable except for mild periumbilical tenderness and orthostatic hypotension. Laboratory testing revealed a white blood count of 8 K/uL, hemoglobin of 14.9 g/dL, serum sodium of 135 mmol/L, serum potassium of 4.1 mmol/L, blood urea nitrogen of 20 mg/dL, creatinine of 1.0 mg/dL, international normalized ratio (INR) of 1.23, D-Dimer of 1221 ng/mL, C-reactive protein of 20 mg/L, and erythrocyte sedimentation rate of 29 mm/hr. Contrast-enhanced computed tomography (CT) of the chest and abdomen was negative for thromboembolism, however, it showed a hazy, misty appearance of the mesentery with multiple prominent lymph nodes. The patient was treated conservatively; warfarin was resumed with heparin bridging. With clinical improvement, the patient was discharged home. DISCUSSION: MP is a benign fibroinflammatory disorder primarily affecting the adipose tissue of the mesentery with a prevalence range between 0.16-0.6%. It typically occurs in the 6th decade of life with a male to female ratio of 2:1. The underlying etiology of MP remains unclear, history of abdominal surgery and trauma were considered predisposing factors in the majority of the cases, in addition to autoimmune disorders and vasculitis. Clinical presentation varies with most of the cases being typically asymptomatic. Symptomatic patients report nonspecific complaints such as abdominal pain, fever, nausea, and fatigue. Physical examination and laboratory workup are usually nonrevealing but palpable masses have been reported. These factors make the diagnosis even more challenging and usually requires a contrast-enhanced CT scan. Hence, high clinical suspicion is required to diagnose MP while investigating otherwise unexplained abdominal pain.