Successful Treatment of Mesenteric Scleritis with Prednisone and Azathioprine Combination Therapy in an Elderly Male

Abstract

Purpose: Sclerosingmesenteritis (SM) also known as, mesenteric panniculitis, retractile mesenteritis or mesenteric fibrosis is a rare fibro inflammatory disorder of unknown etiology that primarily affects the small bowel mesentery. Because of the paucity of published cases the optimal treatment options remained uncertain. Method: A 65-year-old male, with a history of hyperlipidemia, hypertension, diabetes mellitus, gout, and membranous glomerulonephritis, presented with a 6 month history of intermittent abdominal pain, fever, and 20-lbs weight loss. The abdominal pain was generalized, intermittent and dull with no change in his bowel habit. He took daily simvastatin, metoprolol, insulin, and glypizide. He denied history of recent travel overseas or tuberculosis exposure. Physical exam was notable for diffuse generalized abdominal tenderness on palpation but otherwise normal exam. Initial lab work revealed an elevated WBC of 17,000 with 80% Neutrophils, anemia with a Hgb of 9.9. His chem profile was normal with the exception of Cr of 2.5 (his baseline was 2-2.8). He had an elevated ESR and CRP. Infectious work up including urine, blood, and stool cultures, chest X-ray, and PPD test were normal but he was started on empirical antibiotic therapy. A non-contrast CT (due to contrast allergy) was performed which revealed diffuse subtle increased attenuation within the colonic mesenteric fat. Subsequent colonoscopy with random biopsy was performed which was normal. After obtaining surgical consultation, the patient underwent a diagnostic laparoscopy with peritoneal biopsy. Biopsies confirmed the diagnosis of SM with extensive fat necrosis with areas of fibrosis, presence of foamy histiocytes and inflammatory cells with paucity of IgG4-positive plasma cell. Results: Post-operatively he was started on prednisone 50 mg daily for one month and switched to Azathioprine 100 mg with prednisone taper. At 3 months follow-up, he remained afebrile and pain free. His inflammatory markers and WBC had all normalized. Conclusion: Although a relatively benign disease, sclerosing mesenteritis can sometime have a debilitating and fatal course; the need to treat patients with a diagnosis of SM remains debated. Approximately 50% of the patients might not require any treatment however symptomatic patients seem to benefit from treatment. A variety of anti-inflammatory and immunomodulatory agents have been used to treat patients, including steroids, azathioprine, colchicine and tamoxifen, but there is little data on which agents are most successful. In our patient, combination therapy with azathioprine and prednisone taper resulted in significant improvement in the patient's clinical course and lab values.