Pancreatitis and systemic lupus erythematosus: a case report

Lupus Pancreatitis Masquerading as Pancreatic Cancer: A Rare Clinical Presentation

Systemic lupus erythematosus (SLE) is an autoimmune multisystemic inflammatory disease. SLE-associated pancreatitis is uncommon, and pancreatic cancer in SLE is very rare. Imaging findings in SLE with pancreatitis can mimic malignancy. Endoscopic ultrasound with fine-needle aspiration/biopsy can guide in the accurate diagnosis and management of SLE-associated pancreatitis.

Lupus-Associated Pancreatitis

OBJECTIVES

Involvement of the pancreas in systemic lupus erythematosus is rare. The purpose of this article is to provide a detailed review of lupus-associated pancreatitis.

METHODS

We describe 3 patients with lupus-associated pancreatitis and review the English literature of the last 30 years, including the demographic, clinical, therapeutic, and prognostic aspects of this disorder.

RESULTS

There were detailed descriptions of 77 patients, 88% were females. Median age was 27 years. In 44% of the patients pancreatitis developed within 1 year of the diagnosis of lupus, and 84% had active lupus at the time of pancreatitis. Abdominal pain was the most frequent pancreatitis-related symptom (88%), followed by nausea or vomiting (67%). In 97% the diagnosis of pancreatitis was based on laboratory evidence of elevated serum amylase or lipase. Abdominal computerized tomography and ultrasonography did not show signs of pancreatic involvement in 24 and 45%, respectively. The mortality rate was 27%; active lupus and some biochemical abnormalities were significantly associated with increased mortality. Treatment with corticosteroids or azathioprine was not associated with increased mortality. On the contrary, mortality was decreased in patients who were treated with these agents after the onset of pancreatitis (20% mortality, compared with 61% among those who were not treated with steroids for their pancreatitis, P = 0.005).

CONCLUSIONS

Pancreatitis should be suspected in any SLE patient with abdominal pain. Mortality rate is related to both active lupus and some biochemical markers. In most cases, the onset of pancreatitis appears unrelated to previous treatment with steroids or azathioprine. Moreover, treatment with these medications improves prognosis.

Acute pancreatitis in paediatric systemic lupus erythematosus

Acute pancreatitis (AP) rarely complicates the clinical course of systemic lupus erythematosus (SLE). AP as the initial manifestation of SLE is exceptional, but its outcome is often fatal. Corticosteroids have been suspected to play a role in the development of AP, but the therapeutic benefit seems to be far above the risk of exacerbation of pancreatic lesions. We report a 13-y-old girl presenting with arthralgia and malaise, followed by abdominal pain, generalized oedema and haemodynamic instability. Increased CRP (325 ng/ml), serum amylase (14,000 IU/l) and lipase (2500 IU/l) levels suggested AP. Acute anuric renal failure required haemodialysis. Multiorgan involvement suggested SLE, which was confirmed 3 d later by increased anti-ds-DNA levels. Three methylprednisolone pulses were administered promptly, followed by oral prednisone (1.5 mg/kg/d) and six pulses of cyclophosphamide (500 mg/1.73 m2/2 wk). Mycophenolate mofetil was introduced for long-term disease control. Amylase and lipase levels decreased over 4 wk. Renal function was normal after 3 wk and proteinuria negative after 6 wk. This case suggests that steroid pulse therapy should be promptly administered if clinical and biochemical investigations suggest SLE to be responsible for AP. Aggressive treatment may be life saving.

Systemic lupus erythematosus presenting initially with acute pancreatitis and a review of the literature

A patient with systemic lupus erythematosus is reported whose initial clinical presentation was that of acute pancreatitis, confirmed by pancreatic isoamylase elevation and pancreatic enlargement on computerized tomography. A lack of a correlation with steroid therapy and a need to document pancreatitis in a multisystem disease like lupus with radiographic evidence as well as pancreatic isoamylase elevations is emphasized.

Immune complex induced pancreatitis: effect of BN 52021, a selective antagonist of platelet-activating factor

A model of acute pancreatitis was developed by induction of an immune complex mediated hypersensitivity reaction in rats. This acute inflammatory reaction was characterized by intense interstitial edema, neutrophil infiltration and margination, and congestion of small vessels whereas serum amylase levels remained unchanged. Microscopic examination of the pancreatic tissue revealed the presence of immune complex deposition around blood vessels and ducts. Vascular permeability, as measured by Evan's blue extravasation increased by 6 fold. In addition, circulating platelets dropped to 50% of normal levels. Injection of platelet-activating factor (PAF) in the peritoneal cavity of rats also produced an increase in vascular permeability in the pancreas. A selective PAF-antagonist, BN 52021 reduced by approximately 50% the increase in vascular permeability produced by immune complex in the pancreas as well as that elicited by intraperitoneal injection of PAF. These results suggest that PAF plays a role in the pathological manifestations of immune complex-mediated pancreatitis.

Acute pancreatitis in systemic lupus erythematosus: report of a case unrelated to drug therapy

Systemic lupus erythematosus (SLE) is an autoimmune rheumatic disease that can affect most organs or systems. It most frequently involves the joints, skin, and the kidneys. It less commonly involves the central nervous system, heart, and lungs. Acute pancreatitis in SLE is rare. It is usually mild, occurring in association with more severe organ involvement elsewhere. A patient with newly diagnosed SLE is reported who developed acute fulminant pancreatitis unrelated to concomitant drug therapy and who eventually died of complications including a systemic fungal infection related to this.

Acute pancreatitis in systemic lupus erythematosus

Lethal acute pancreatitis developed in a 16-year-old Caucasian woman suffering from systemic lupus erythematosus. Until the time of onset of pancreatitis, the patient's medications included prednisone, furosemide, ethacrynic acid and chlorthalidone, all of which have been related to pancreatitis. At autopsy, no specific signs of autoimmune activity were found in the diseased pancreatic tissue. A review of the literature shows that information on the association of pancreatitis and SLE is scarce. This case illustrates the dilemma of pathogenesis and therapy of acute pancreatitis in SLE and the need for further investigation.