Common Complaints Masking a Rare Disease: Abdominal Pain and Diarrhea as the Presenting Signs of Lupus Enteritis

Abstract

Systemic Lupus Erythematosus (SLE) is an autoimmune condition characterized by joint pains, rash, and other systemic manifestations. Herein we describe a patient who presented with GI complaints and was later discovered to have lupus enteritis (LE), a rare complication of SLE. A 28-year-old Asian woman with family history of Crohn's disease presented for abdominal pain, watery diarrhea, and bilious emesis. Initial labs were unremarkable with a negative pregnancy test. CT scan revealed mild ascites, mild diffuse enteritis, and sigmoid colitis. Stool cultures, O & P and C. diff toxin were all negative. She was treated with ciprofloxacin and metronidazole with improvement of symptoms and then discharged. She returned for recurrence of symptoms and repeat CT showed mild ascites, rapidly progressing enteritis with severe involvement of the ileum and descending colon. Again, labs were grossly normal including CMP, CBC, ESR, CRP, C. diff., and stool cultures. Colonoscopy was consistent with acute enterocolitis without mucosal changes or evidence of Ulcerative colitits or Crohn's disease. Terminal ileum biopsies were unremarkable. At this point, a rheumatological workup was initiated and she was started on steroids for presumed autoimmune etiology. Her symptoms subsided and ANA returned at 1:320 speckled pattern, complement C3 and C4 were low. She was diagnosed with LE and discharged on oral prednisone. LE is a rare manifestation of SLE that is not fully understood. Given its overlapping symptoms with common GI illnesses, the diagnosis is challenging and easily missed. Common symptoms of LE include abdominal pain (97%), vomiting, diarrhea, and fever. Laboratory features include low complement levels (88%), anemia, leukopenia, lymphopenia, and thrombocytopenia. Median CRP level is 2.0 mg/dL. Imaging findings include bowel wall edema with target sign, ascites, hydronephrosis, mesenteric abnormalities and bowel dilation. If left untreated, LE can progress to intestinal necrosis and perforation. In this case, the family history of Crohn's disease initially led us to an inflammatory cause. Only after common etiologies were ruled out, was an autoimmune etiology explored. LE can be considered in patients with prior diagnosis of an autoimmune disorder who present with recurrent and intractable abdominal pain, diarrhea and emesis. LE has an excellent response to steroids. If promptly treated, symptoms and disease processes are reversible.1560 Figure 1. Abdominal CT images of bowel-wall thickening and enhancement known as the “target sign” (blue/red arrows). The abnormalities are non-specific and can also be seen in patients with Inflammatory Bowel Disease and other gastrointestinal conditions.