Lupus Mesenteric Vasculitis With GI and Genitourinary Tract Involvement

Abstract

A53-year-old woman presented with watery diarrhea of 6 months’ duration. She had no systemic disease or surgical history and did not take any medications. The associated symptoms included nausea, vomiting, dull abdominal pain without radiation, urinary urgency, frequency, and incontinence, and marked body weight loss (21 kg in 6 months). On admission, the physical examination showed hypoactive bowel sounds with slight periumbilical tenderness. Neither rebound tenderness nor guarding was elicited. No leg edema or skin rash was noted. Laboratory data showed no leukocytosis, mild increase of C-reactive protein level (1.69 mg/dL), mildly increased liver function tests (aspartate aminotransferase, 84 IU/L; alanine aminotransferase, 59 IU/L), and hypoalbuminemia (2.1 g/dL). Urine analysis showed proteinuria and pyuria. Routine stool analysis showed no evidence of infection or bleeding. Enhanced computed tomography of the abdomen showed diffuse wall thickening of stomach, small bowel, colon, and rectum (Figure A, target sign, arrow) and prominent engorgement of the mesenteric vessels with a palisade pattern (Figure B, comb sign, arrow). Bilateral hydroureteronephrosis and swelling of the bladder wall also were noted (Figure C, arrow). Further laboratory studies showed increased antinuclear antibody level (1:320, diffuse type), increased anti–double-stranded DNA (85 IU/mL), and low complement level (C3, 32 mg/dL; C4, 5.87 mg/dL). The clinical presentation and computed tomography image were compatible with lupus mesenteric vasculitis and lupus cystitis. The patient received cyclophosphamide and methylprednisolone pulse therapy, followed by steroid maintenance treatment. The patient’s clinical condition and follow-up computed tomography 17 days after admission showed significant improvement. Lupus mesenteric vasculitis is a rare presentation (0.2%–9.7%) among patients with systemic lupus erythematosus (SLE), but it is more common in SLE patients with abdominal pain (29%–65%). Typical image findings of lupus mesenteric vasculitis include focal or diffuse bowel-wall thickening with target sign, prominent engorgement of mesenteric vessels with comb sign, and ascites. Lupus cystitis frequently is associatedwith bowel involvement. Edema of the vesical triangle resulted in hydronephrosis and contraction of the bladder, and further induced urinary frequency and inflammation of the bladder. It is worthwhile to note that vasculitis and cystitis can be the initial manifestations of SLE.