Elusive Enteritis: A Case of Rapidly Evolving Lupus

Abstract

A 33 year old woman with history of systemic lupus erythematosus (SLE) presented with epigastric pain and watery diarrhea for one month duration. Further history revealed she had been off maintenance medications for SLE including belimumab and prednisone for the past month. Initial exam was notable for tachycardia 34 beats/min, tachypnea 22 breaths/min, fever to 102.9F and diffuse abdominal tenderness. CT abdomen was obtained showing thickened bowel loops concerning for nonspecific enteritis. Given fevers and CT findings, broad spectrum antibiotics were initiated with no improvement in symptoms as well as worsening shortness of breath. Repeat CT abdomen 24 hours later showed significantly worsening enteritis and new ascites. C. difficile toxin and stool cultures were negative. Initial lab data was notable for albumin 2.0 g/dL (down from baseline 3.6 g/dL) and platelets of 574 k/u, with normal liver function tests, no anemia or leukocytosis. The constellation of diarrhea and hypoalbuminemia with enteritis on CT raised concern for a protein-losing enteropathy. GI was consulted, and EGD was performed showing moderate inflammation and duodenal biopsy obtained with non-specific findings. Elevated ESR (95 mm/hr,) and CRP (141.4 mg/L) suggested an acute inflammatory process. An ANA titer of 1:160, anti-RNP and anti-SM antibodies, dsDNA greater than 180 IU/L and low complement levels supported active SLE flare or mesenteric vasculitis. Rheumatology was consulted and began prompt treatment with methylprednisone. At follow up weeks, her symptoms diarrhea and abdominal pain drastically improved suggesting resolution of her enteritis. This case emphasizes the importance of early identification of lupus enteritis and distinguishing it from infectious colitis. About 25-33% of patients with SLE may present with lupus enteritis. Presenting symptoms include abdominal pain, diarrhea and may be insidious in onset as in our case. Complement levels are typically low with elevated inflammatory markers. Duodenal biopsies are often normal and full thickness biopsies may be required. A high suspicion of the diagnosis is needed. Our patient was started on high dose steroids with rapid improvement in diarrhea and pain. CT findings can be dramatically altered depending on how early steroids are initiated. This case demonstrates that timely initiation of steroid therapy can control vasculitis and lead to drastic symptom resolution in patients with lupus enteritis.