Bowel involvement in systemic lupus erythematosus: Crohn's disease or lupus vasculitis?

Coexistence of Crohn's disease and systemic lupus erythematosus: a case report and literature review

Lupus enteritis and Crohn's disease are two common immune diseases involving the gastrointestinal tract. There are many similar clinical manifestations, therefore it is very difficult to distinguish between them. The digestive system is involved anywhere from 8 to 40% of patients with systemic lupus erythematosus (SLE) and up to 53% of these go on to develop lupus enteritis. In patients with Crohn's disease, 6-40% were presented with oral mucosa ulceration, nodular erythema of skin, arthritis, eye disease and other extraintestinal manifestations. The concomitant of Crohn's disease and SLE is extremely rare; however, here we described a case of concomitant Crohn's disease and SLE characterized by recurrent intestinal obstruction. A systematic literature review of lupus concomitant with Crohn's disease was then conducted.

Lupus enteritis: an uncommon manifestation of systemic lupus erythematosus

We report the case of a 25-year-old Iraqi woman who had multiple hospitalizations at an outside hospital for abdominal pain, nausea, and diarrhea without any evidence of systemic lupus erythematosus. Laboratory investigations finally showed a positive antinuclear antibody (1280), positive anti-dsDNA, anti-β2 glycoprotein I, low complement, positive Coombs tests, and leukopenia. A kidney biopsy showed ISN class II lupus nephritis. An ileal biopsy and angiogram were unremarkable. A computed tomography showed marked and dramatic bowel edema involving the small and large bowel ("target sign"), dilatation of intestinal segments, engorgement of mesenteric vessels ("comb sign"), and increased attenuation of mesenteric fat. These cardinal signs on computed tomography scan led to the correct diagnosis of lupus enteritis. Treatment was commenced with high-dose corticosteroids followed by mycophenolate mofetil, hydroxychloroquine, and then oral cyclophosphamide, but failed. The patient was eventually treated with the Euro-Lupus intravenous cyclophosphamide regimen, which resulted in significant clinical and radiological resolution.

Inflammatory bowel disease and lupus: a systematic review of the literature

Coexistence of systemic lupus erythematosus (SLE) should be considered in patients with inflammatory bowel disease (IBD) and complex extraintestinal manifestations and the diagnosis of IBD could be established either before or after the diagnosis of SLE. Differential diagnosis of concomitant SLE and IBD is difficult and should always exclude infectious conditions, lupus-like reactions, visceral vasculitis and drug-induced lupus. The underlying mechanism by which 5-ASA/sulphasalazine induces SLE or lupus-like syndromes is not clear and high awareness for possible predictive factors is demanded for early prevention. In most cases the symptoms from drug-induced lupus have been reversible after the discontinuation of the drug and response to steroids is favorable. Treatment of patients co-diagnosed with SLE and IBD may include corticosteroids, immunosupressants and hydroxychloroquine. In severe lupus and IBD patients cyclophosphamide pulse may be of benefit while infliximab may be beneficiary in patients with lupus nephritis. However, the role TNFalpha plays in humans with SLE and IBD is controversial and data on the likely effects of blocking TNFalpha on anti-DNA autoantibody production is always of interest.

Coexistence of Crohn's disease in a patient with systemic lupus erythematosus

The concurrence of inflammatory bowel disease with systemic lupus erythematosus (SLE) is rare. The concomitant diagnosis of Crohn's disease and SLE is even more rare. The patient, a 40-year-old woman, was admitted to our hospital because of relapsing episodes of abdominal pain, diarrheas upper and lower extremities arthralgias, Raynaud's phenomenon with positive antinuclear antibodies, and fever for the last 2 years. The patient was diagnosed elsewhere with SLE and treated with hydroxychloroquine. Her medical history also included tonsillectomy and total hip replacement after a car accident. Family history was unremarkable. Physical examination was unremarkable except of very mild pain at lower left abdominal quadrant. Laboratory tests showed erythrocyte sedimentation rate at 32 mm/h, C-reactive protein at 36 mg/dl, positive rheumatoid factor, and increased C3, C4, positive antinuclear antibodies with the presence of anti-Sm and anti-RNP antibodies. Ileocolonoscopy revealed colonic inflammation with ulcers and pseudopolyps. Subsequent biopsies were diagnostic of Crohn's disease. Patient was diagnosed with Crohn's colitis concomitant to systemic lupus erythematosus and was started on therapy with azathioprine 2 mg/Kg, methylprednisolone 16 mg/d with slow tapering, mesalazine 1.5 g/day, and hydroxychloroquine. Patient is in excellent health status on the six-month follow-up.

Cytomegalovirus enteritis mimicking Crohn’s disease in a lupus nephritis patient: A case report

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract has been reported in both immunocompetent and, more frequently, in immunocompromised patients. We describe a case of a 19-year-old male who developed CMV infection of the terminal ileum while receiving immunosuppression for lupus nephritis. This was a distinctly unusual site of infection which clinically mimicked Crohn’s ileitis. We note that reports of terminal ileal CMV infection have been infrequent. Despite a complicated hospital course, ganciclovir therapy was effective in resolving his symptoms and normalizing his ileal mucosa. This report highlights the importance of accurate histological diagnosis and clinical follow-up of lupus patients with GI symptoms undergoing intense immunosuppression.

Systemic lupus erythematosus and inflammatory bowel disease

We hereby summarize a case reported by the authors, as well as all of the previously reported cases, of patients suffering from both systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD) that have been published in the English literature. In most cases, SLE was diagnosed prior to IBD, and the latter was of the ulcerative colitis subtype. Interestingly, the first disease diagnosed was almost never active at the time the second disease manifested itself. Patients with both diseases tended to have less photosensitivity, less arthritis, and less serositis than patients with SLE alone. There were no cases with neurological disorders or overt nephritis. All of these patients had anti-dsDNA and there was a tendency towards more anemia and thrombocytopenia. These patients had a relatively benign course with no flare-ups of lupus during follow-up and a favorable course of their bowel disease as well.

Systemic vasculitis: a cause of indeterminate intestinal inflammation

OBJECTIVES

Indeterminate intestinal inflammation may result from a variety of inflammatory conditions in addition to ulcerative colitis and Crohn disease. The primary systemic vasculitides may present with intestinal inflammation and an indeterminate colitis. We set out to describe a series of children with primary systemic vasculitis who initially presented with clinical features suggestive of inflammatory bowel disease (IBD) to establish criteria that might help discriminate between IBD and primary systemic vasculitis.

METHODS

Ten children (6 boys, median age at presentation 8.9 years, range 0.9-14.5 years) satisfied inclusion criteria.

RESULTS

All had abdominal pain, weight loss, diarrhea (6 of 10 bloody) and laboratory evidence of a severe acute phase response. Extraintestinal clinical features included vasculitic rash, renal impairment, myalgia, testicular pain and polyarthritis. Endoscopy showed vascular changes or other macroscopic findings suggestive of vasculitis in 5 of 10 patients. Gut histology revealed indeterminate chronic inflammatory mucosal changes and one patient with small artery fibrinoid necrosis in the submucosal vessels. Extraintestinal biopsy was performed in 6 patients and had a higher yield for the demonstration of vasculitis than intestinal biopsy. The results of selective visceral angiography was suggestive of vasculitis in all patients, but was normal in 7 cases of treatment-unresponsive classic IBD. Treatment comprised corticosteroid and azathioprine in all patients. Cyclophosphamide was given to 7 of 10 patients.

CONCLUSIONS

Extraintestinal manifestations and inflammatory responses that may be disproportionate to the degree of intestinal inflammation provide clues to the presence of an underlying primary systemic vasculitis, and these data suggest that selective visceral angiography plays a key role in the diagnosis of vasculitis in this context. It is important to identify and treat any vasculitic component because failure to do so may result in consequential morbidity or mortality.

Eosinophilic gastroenteritis associated with systemic lupus erythematosus

Eosinophilic gastroenteritis is an uncommon disease with an obscure etiology, although associations with allergy, the idiopathic hypereosinophilic syndrome, and connective tissue disease have been reported. We present the case of a 37-year-old woman with a history of idiopathic thrombocytopenic purpura who presented with refractory nausea, vomiting, and abdominal pain. Imaging studies were significant for bowel wall thickening and ascites, while laboratory studies revealed a positive antinuclear antibody (ANA), a positive anti-double stranded (DS) DNA antibody, low complement, and proteinuria. Exploratory laparotomy with gastric and small bowel biopsies established the diagnosis of eosinophilic gastroenteritis. In addition, the patient met clinical criteria for the diagnosis of systemic lupus erythematosus. Previous studies have described eosinophilic gastroenteritis in patients with scleroderma, polymyositis, or dermatomyositis. This is the first report to our knowledge of an individual with eosinophilic gastroenteritis and systemic lupus erythematosus.

[Association of disseminated lupus erythematosus and Crohn's disease]

INTRODUCTION

Association of Crohn's disease and systemic lupus erythematosus is infrequent. We report an observation of Crohn's disease that appeared in an 18-year-old woman followed-up for systemic lupus erythematosus for four years.

EXEGESIS

The patient had all the clinical, biological and histological criteria of Crohn's disease and systemic lupus erythematosus was diagnosed according to the American Rheumatism Association criteria. On the base of this observation, we discuss the digestive manifestation of systemic lupus erythematosus and extradigestive manifestations of Crohn's disease.

CONCLUSION

The immunological background of both diseases was proposed to explain the mechanism of this rare association.

A review of gastrointestinal manifestations of systemic lupus erythematosus

In this review, we analyse critically the effects of systemic lupus erythematosus (SLE) on the gastrointestinal (GI) tract from mouth to anus, attempting to distinguish the features that are most likely to be due to therapy. GI manifestations of SLE include mouth ulcers, dysphagia, anorexia, nausea, vomiting, haemorrhage and abdominal pain. GI vasculitis is usually accompanied by evidence of active disease in other organs. Early recognition of the significance of these symptoms offers the best opportunity to improve the symptoms and to aid long-term survival.

Rectal ulcers: a rare gastrointestinal manifestation of systemic lupus erythematosus

A patient with systemic lupus erythematosus (SLE) developed a rectal ulcer and sepsis from colonic bacteria. At that time she had no other clinical manifestations of SLE. Histopathologic examination of the biopsies taken from the ulcer found evidence of vasculitis. Treatment with high-dose systemic steroids healed the ulcer clinically and endoscopically, but symptoms recurred when steroids were tapered. The patient was referred for surgery. This is a rare but dangerous complication of SLE and can be the only clinical manifestation of the disease.

Vasculitis associated with connective tissue disease

Vasculitis, one of the clinical features shared by connective tissue diseases, should be considered when signs and symptoms are observed that may result from tissue ischaemia due to damaged vessels. The lesions seem to result from specific and non-specific immunopathogenic mechanisms targeted at the vascular endothelium. Because of the therapeutic implications it is the physician's responsibility to document its presence and the extent of organ involvement. Prompt institution of immunosuppressive drugs may be lifesaving. On the other hand there are some forms of vasculitis accompanying connective tissue disease which are entirely benign. Patients with infarctions of extremities and progressive functional disturbances of the central nervous system or internal organs because of vasculitis should be treated with high dosages of corticosteroids in combination with cytostatic drugs. Remissions are frequently obtained within three to six months of initiation of treatment and can be maintained with a less aggressive treatment regimen.

Crohn disease in systemic lupus erythematosus: a case report

A 15-year-old girl with systemic lupus erythematosus (SLE) in remission for 3 years showed abdominal pain and bloody stools. No evidence for exacerbation of SLE was obtained. An air-contrast barium enema examination and colonoscopy revealed findings typical of Crohn disease. Despite the rarity of the combination, patients with SLE showing gastrointestinal manifestations might need evaluation for Crohn disease.

Protein-losing enteropathy in systemic lupus erythematosus

Two patients with systemic lupus erythematosus (SLE) presented with anasarca, pleural effusions and severe hypoalbuminema. Both were demonstrated to have protein-losing enteropathy, a rare complication of SLE. Other causes of gastrointestinal protein loss were excluded. There were marked similarities in both cases including circulating ANF with speckled staining, anti-(U1)RNP antibodies and low serum complement levels. Complete remission was achieved in both with prednisolone. Anti-(U1)RNP may be a marker for a subset of SLE in which protein-losing enteropathy is a major manifestation.

Pathologic features of gastrointestinal tract lesions in childhood-onset systemic lupus erythematosus: study of 26 patients, with review of the literature

A review of the gastrointestinal tracts of 26 autopsied cases of childhood-onset systemic lupus erythematosis (SLE) showed the single most common pathologic finding to be chronic nonspecific mucosal infiltration (96%). The most frequent general category was ischemic bowel lesions, attributable to vascular lesions of SLE (60%) or to nonocclusive causes of circulatory insufficiency such as congestive heart failure, uremia, or shock (40%). Complications of ischemic bowel lesions included secondary invasion by opportunistic organisms such as Candida (9 patients), pneumatosis intestinalis (1), and perforation of a gastroesophageal ulcer (1). Colonic ulcers, clearly ischemic in etiology, were noted in 6 patients, none of whom had other bowel lesions resembling those of Crohn's disease or ulcerative colitis. Other relevant findings included ascites (88%), peritoneal inflammation or fibrosis (42%), upper esophageal skeletal muscle fiber atrophy (8%), heterotopic calcification of gastric mucosa (12%), and severe intestinal mucus inspissation (4%). Correlations between the various lesions and clinical manifestations, and possible etiologic and pathogenetic mechanisms of these lesions, are discussed.