Studies of the pathogenesis of interstitial cystitis, obstructive uropathy, and intestinal malabsorption in a patient with systemic lupus erythematosus

In lupus cystitis, is the urinary tract dilated or obstructed?

OBJECTIVES

Lupus cystitis is a rare but serious complication of systemic lupus erythematosus (SLE) that can cause permanent bladder dysfunction, leading to irreversible deterioration of kidney function. We report two cases of SLE with lupus cystitis who showed different images from the same cause of disease.

METHODS

Patient 1, a 67-year-old woman diagnosed with SLE presented with persistent dysuria for 3 weeks with sudden headache and vomiting. She was hospitalized because of acute kidney injury; the serum creatinine level was 10.68 mg/dL. Computed tomography (CT) showed significant bilateral ureteral stenosis and bilateral hydronephrosis. Patient 2, a 45-year-old woman diagnosed with SLE presented with dysuria requiring self-catheterization. CT showed significant bilateral ureteral dilatation and bilateral hydronephrosis.

RESULTS

In patient 1, the right kidney was afunctional. Left nephrostomy was performed on Day 2. Her serum creatinine returned to the normal range. In patient 2, After admission, she changed to an indwelling bladder catheter. Her serum creatinine level improved from 2.04 to 1.31 mg/dL.

CONCLUSION

In patients with lupus cystitis, the urinary tract is commonly dilated, but stenosis has been seen in rare case. Physicians should be careful in diagnosing it.

Very Severe and Refractory Noninfectious Cystitis in Patients with Systemic Lupus Erythematosus: Potential Role of Rituximab Therapy

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease with various clinical manifestations, including, rarely, a form of interstitial cystitis (lupus cystitis, LC). LC can be asymptomatic and usually has discrete symptoms that improve with conventional therapies available for SLE and/or typical interstitial cystitis. A very severe and refractory form is rarely described. In this study, we present four patients with SLE and a very severe form of noninfectious cystitis refractory to the different forms of treatment described. The clinical descriptions of the cases, demographic factors, manifestations associated with SLE, and clinical and paraclinical manifestations related to cystitis, treatments, and outcomes are provided. A proposal for the pathogenesis of this condition is based on the common findings of these patients, including the fact that three were in SLE remission and all four receiving rituximab as induction and/or maintenance therapy.

Lower CH50 as a predictor for intractable or recurrent lupus enteritis: A retrospective observational study

OBJECTIVES

Lupus enteritis (LE) is a rare but well-known gastrointestinal manifestation of systemic lupus erythematosus (SLE). This study was conducted to identify prognostic factors associated with poor responses in patients with LE.

METHODS

We consecutively registered patients diagnosed with LE between January 2009 and October 2019, and retrospectively compared their clinical characteristics based on whether they had good or poor responses to treatment.

RESULTS

A total of 13 patients (17 episodes) were included. The median age was 41 years, and 12 patients were female. A comparison of clinical characteristics between groups revealed similar computed tomography (CT) findings. However, serum CH50 levels were significantly lower in the poor response group (median [interquartile ranges (IQR)]; 29.2 [25.3-46.9] U/mL vs 19.3 [7.8-24.0] U/mL, p = .0095). More patients in the poor response group had higher titers of anti-cardiolipin β2-glycoprotein I antibody (anti-CL β2GPI Ab) and were started on glucocorticoids (GCs) at moderate doses. In multivariable analysis, serum CH50 level was independently associated with poor response to induction therapy.

CONCLUSION

Lower levels of CH50 at the time of initial treatment predicted inadequate treatment response in patients with LE.

Lupus intestinal pseudo-obstruction and hydronephrosis: Case report

INTRODUCTION

Intestinal pseudo-obstruction (IPO) is a rare and life-threatening complication of lupus.

PATIENT CONCERNS

A patient with long-standing lupus developed recurrent abdominal pain and distension as well as nausea and emesis.

DIAGNOSIS

Imaging showed dilated small bowel loops with air-fluid levels and bowel wall thickening. She also had bilateral hydronephrosis.

INTERVENTIONS

She was given high-doses of intravenous steroids and cyclophosphamide.

OUTCOMES

Her symptoms resolved within a week of starting immunosuppression. She was eventually transitioned to mycophenolate mofetil. She remained in remission and immunosuppression was successfully stopped after 1 year.

CONCLUSIONS

Intestinal pseudo-obstruction is a rare complication of lupus that is often seen in association with ureterohydronephrosis and interstitial cystitis. This clinical syndrome is thought to be because of smooth muscle dysmotility of the gastrointestinal and genitourinary tracts, although the exact mechanism of dysmotility remains unknown. This condition is often responsive to immunosuppression if recognized and treated promptly.

Asymptomatic Lupus Cystitis with Bilateral Hydronephrosis

Lupus cystitis is a rare complication of systemic lupus erythematosus (SLE). It is characterized by an increase in bladder wall thickness and may be associated with hydroureteronephrosis. Reports, mostly from East Asian countries, indicate that lupus cystitis usually presents with gastrointestinal tract symptoms such as diarrhea, nausea, or abdominal pain. Lower urinarytract symptoms such as dysuria, nocturia, polyuria, and suprapubic pain are also common presenting symptoms. We report a 22-year-old female patient who presented at Cipto Mangunkusumo Teaching Hospital in Indonesia, with profuse and prolonged vaginal bleeding without any other accompanying symptoms. She had a history of polyarthralgias, fever, bleeding gums, anemia, and thrombocytopenia 3 months earlier. Abdominal ultrasound examination revealed bilateral hydronephrosis and a thickened bladder wall; the other organs were normal. Laboratory examination confirmed the diagnosis of SLE complicated by lupus nephritis and lupus cystitis. The patient responded well to the treatment with methylprednisolone. The vaginal bleeding stopped within 2 days, and the laboratory parameters improved. She was discharged on oral methylprednisolone and is scheduled for detailed workup after 1 month.

Is there an ethnic difference in the prevalence of lupus cystitis? A report of six cases

Lupus cystitis was rare but frequently resulted in obstructive uropathy and had a strong association with gastrointestinal(GI) symptoms. We treated six patients with systemic lupus erythematosus(SLE) and obstructive uropathy from January 1996 to December 2001 in a university hospital. Evidence of cystitis was obtained from cystoscopic biopsy or the presence of thickened bladder wall in image study. Similar to other reports, five patients had GI manifestations such as abdominal pain, nausea/vomiting, diarrhoea or ileus. In addition, mesenteric lymphadenopathy or pancreatitis was noted in three patients. Two patients had been treated for idiopathic thrombocytopenicpurpura (ITP), four and 20 years ago, respectively. All six patients had antibodies to double-stranded DNA (dsDNA). Five patients each had antibodies to cardiolipin (IgG aCL) or SSA. The high prevalence of anti-SSA had also been reported in Chinese lupus patients with intestinal pseudo-obstruction, a clinical manifestation frequently associated with bilateral ureterohydronephrosis. Two patients died of intractable infection after the surgical procedures for persistent ureterohydronephrosis and both patients had antibodies to ribosomal P proteins. Lupus cystitis might not be so rare in Chinese patients with SLE. The diagnosis should be kept in mind when lupus patients have urinary and/or GI symptoms.

Clinical outcomes of hydronephrosis in patients with systemic lupus erythematosus

AIM

Hydronephrosis is a rare complication of systemic lupus erythematosus (SLE). Bladder and/or gastrointestinal involvement in SLE are associated with development of hydronephrosis, but the management and treatment outcomes of hydronephrosis are largely unknown. Therefore, we investigated the clinical manifestations and factors associated with the treatment response in patients with SLE complicated by hydronephrosis.

METHOD

A retrospective analysis was performed of all 634 SLE patients who underwent computed tomography and/or ultrasonography between January 1998 and December 2013. We reviewed the clinical characteristics and treatment outcomes of patients with SLE-associated hydronephrosis.

RESULTS

Hydronephrosis was identified in 15 patients with SLE complicated by cystitis and/or enteritis. All patients were treated initially with moderate to high doses of corticosteroids. A follow-up imaging study showed that 11 (73.3%) of 15 patients experienced improvements in hydronephrosis, and urinary obstruction was resolved without urological intervention in the majority of these patients (8/11, 72.7%). The four patients who experienced no improvement in hydronephrosis were older than those who responded to treatment (median age [interquartile range]; 43.0 [37.5-53.0] years vs. 28.0 [21.0-38.5] years; P = 0.026). In addition, delayed treatment (≥ 1 month after onset of symptoms) with corticosteroids was more frequently observed in the non-responding patients than in the responding patients (P = 0.011).

CONCLUSION

Our findings suggest that treatment with corticosteroids alone leads to favorable outcomes in patients with SLE-associated hydronephrosis, except when treatment is delayed, particularly in elderly patients.

Clinical analysis of 61 systemic lupus erythematosus patients with intestinal pseudo-obstruction and/or ureterohydronephrosis: a retrospective observational study

The objective of this article is to investigate the clinical features of intestinal pseudo-obstruction (IPO) and/or ureterohydronephrosis in systemic lupus erythematosus (SLE). Sixty-one SLE patients with IPO and/or ureterohydronephrosis were analyzed retrospectively. A total of 183 cases were randomly selected as controls from 3840 SLE inpatients without IPO and ureterohydronephrosis during the same period. Patients were assigned to 1 of the 3 groups (SLE with IPO and ureterohydronephrosis, SLE with IPO, and SLE with ureterohydronephrosis). The clinical characteristics, treatments, and prognosis were compared between the 3 groups. There were 57 females and 4 males, with a mean age of 32.0 years. IPO was the initial manifestation of SLE in 49.1% of the cases, whereas ureterohydronephrosis in 32.5%. All patients were initially treated with a high-dose steroid. Thirty-one of these patients (50.8%) also received intravenous methylprednisolone pulse therapy. Two patients died of bowel perforation and lupus encephalopathy, and the other 59 patients (96.7%) achieved remission after treatment. The incidences of fever, glomerulonephritis, nervous system involvement, serositis, erythrocyte sedimentation rate elevation, hypoalbuminemia, hypocomplementemia, and anti-SSA antibody positivity were significantly higher in patients with IPO and/or ureterohydronephrosis than in the control group (without IPO and ureterohydronephrosis). Also, patients with IPO and/or ureterohydronephrosis had higher SLE Disease Activity Index scores than control patients. Compared with SLE patients with IPO, the patients with IPO and ureterohydronephrosis had a significantly higher incidence of gallbladder wall thickening, biliary tract dilatation, and serositis, whereas the patients with ureterohydronephrosis had less mucocutaneous involvement and serositis. Eight of the 47 IPO patients who initially responded well to immunotherapy relapsed; however, all responded well to retreatment with adequate immunotherapy. Of these 8 patients, 4 relapsed following poor compliance and self-discontinuation of steroid or immunosuppressant therapy. The rate of poor compliance with immunotherapy and the number of organ systems involved in patients in the recurrent IPO group were significantly higher than those in the nonrecurrent IPO group. IPO and ureterohydronephrosis are severe complications of SLE. As patients usually respond readily to early optimal steroid treatment, early diagnosis and timely initiation of glucocorticoid are important to relieve symptoms, prevent complications, and improve prognosis.

Lupus cystitis: An unusual presentation of systemic lupus erythematosus

Lupus cystitis is a rare complication of systemic lupus erythematosus (SLE) and occurs in association with gastrointestinal symptoms. This rare disorder has been reported mainly from Japan. We report a 20 year old female who diagnosed as having SLE associated with paralytic ileus and chronic interstitial cystitis. Treatment with intravenous methylprednisolone, cyclophosphamide pulse therapy followed by oral prednisolone and azathioprine led to amelioration of manifestations. Later she developed lupus nephritis which was treated with mycophenolate mofetil.

Chance, genetics, and the heterogeneity of disease and pathogenesis in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a remarkably complex and heterogeneous systemic autoimmune disease. Disease complexity within individuals and heterogeneity among individuals, even genetically identical individuals, is driven by stochastic execution of a complex inherited program. Genome-wide association studies (GWAS) have progressively improved understanding of which genes are most critical to the potential for SLE and provided illuminating insight about the immune mechanisms that are engaged in SLE. What initiates expression of the genetic program to cause SLE within an individual and how that program is initiated remains poorly understood. If we extrapolate from all of the different experimental mouse models for SLE, we can begin to appreciate why SLE is so heterogeneous and consequently why prediction of disease outcome is so difficult. In this review, we critically evaluate extrinsic versus intrinsic cellular functions in the clearance and elimination of cellular debris and how dysfunction in that system may promote autoimmunity to nuclear antigens. We also examine several mouse models genetically prone to SLE either because of natural inheritance or inheritance of induced mutations to illustrate how different immune mechanisms may initiate autoimmunity and affect disease pathogenesis. Finally, we describe the heterogeneity of disease manifestations in SLE and discuss the mechanisms of disease pathogenesis with emphasis on glomerulonephritis. Particular attention is given to discussion of how anti-DNA autoantibody initiates experimental lupus nephritis (LN) in mice.

Lupus mesenteric vasculitis: clinical features and associated factors for the recurrence and prognosis of disease

OBJECTIVE

To evaluate the clinical characteristics of lupus mesenteric vasculitis (LMV) and identify the potential factors and appropriate treatments that are associated with disease relapse and prognosis in LMV.

METHODS

A retrospective cohort study was performed among patients admitted to the First Affiliated Hospital of Sun Yet-sen University between 2002 and 2011. Demographic information, clinical symptoms, laboratory findings, imaging characteristics like abdominal CT scan, ultrasonography, medications including corticosteroid, cyclophosphamide, and other immunosuppressive agents, and outcomes were documented. The endpoints of the study were defined as occurrence of severe complications that needed surgical intervention, disease recurrence, or death.

RESULTS

Out of 3823 systemic lupus erythematosus (SLE) patients, 97 were diagnosed with mesenteric vasculitis with the overall prevalence of 2.5%. Among these 97 LMV patients, 13 died because of serious complications (13/97, 13.4%) and 2 presented intestinal perforation during the induction therapy stage. The logistic regression multivariate analysis indicated that leukopenia [peripheral WBC, odds ratio (OR) = 0.640, 95% confidence interval (CI): 0.456-0.896, P = 0.009], hypoalbuminemia (serum albumin, OR = 0.891, 95% CI: 0.798-0.994, P = 0.039) and elevated serum amylase (OR = 7.719, 95% CI: 1.795-33.185, P = 0.006) were positively associated with the occurrence of serious complications, while intravenous cyclophosphamide (CYC) therapy inhibited the occurrence of serious complications (OR = 0.220, 95% CI: 0.053-0.903, P = 0.036). A total of 79 patients who achieved remission were followed-up for 2-96 months and 18 cases experienced disease relapse (18/79, 22.8%). The statistical analysis adjusted by Cox proportional hazards models indicated that high-dose CYC therapy (≥ 1.0 g/m(2)/month) was a protective factor for disease relapse and led to better outcomes [hazard ratio (HR) = 0.209, 95% CI: 0.049-0.887, P = 0.034], while the severe thickness of the bowel wall (>8mm) was a risk factor (HR = 7.308, 95% CI: 1.740-30.696, P = 0.007). LMV and lupus cystitis occurred concurrently in 22 (22/97, 22.7%) patients, and the symptoms of urinary tract resolved after treatment with corticosteroid and immunosupressants.

CONCLUSION

LMV is one of the serious complications of SLE with high mortality. The current study demonstrated that leukopenia, hypoalbuminemia, and elevated serum amylase were associated with severe adverse events, while CYC therapy led to better outcomes during remission-induction stage. Severe thickness of the bowel was a risk factor while high-dose CYC therapy was a protective factor for disease relapse in intensification therapy stage. It is necessary to evaluate the urinary tract involvement once LMV is diagnosed due to the frequent coexistence of these 2 diseases.

Clinical features of lupus cystitis complicated with hydroureteronephrosis in a Chinese population

OBJECTIVE

Lupus cystitis is a relatively rare complication of systemic lupus erythematosus (SLE). The clinical characterization of it remains obscure. We sought to provide insight for timely recognition and diagnosis of lupus cystitis, and for efficacious management of this disease entity.

METHODS

The clinical files of 18 patients with lupus cystitis treated at Peking Union Medical College Hospital were reviewed. Clinical manifestations, laboratory investigations, therapeutic measurements, and clinical outcomes were analyzed.

RESULTS

There were both male and female patients with a wide range of ages. The interval from onset of SLE to hydroureteronephrosis varied from 0 to 5 years. The most common clinical presentations were gastrointestinal (GI) symptoms, while urinary symptoms were less common and relatively mild. Lupus nephritis often presented concomitantly with lupus cystitis but was relatively less active pathologically. Laboratory findings showed a high rate of positive anti-SSA. Therapy of prednisone plus cyclophosphamide was effective for lupus cystitis. Delayed diagnosis and treatment may lead to irreversible obstructive uropathy and permanent loss of renal function.

CONCLUSION

Lupus cystitis may not be so rare as has been thought. The diagnosis of lupus cystitis should be considered when patients with SLE present with GI symptoms, and therapy should begin as early as possible.

Recurrent urinary tract infections and bladder dysfunction in systemic lupus erythematosus

To assess bladder function in systemic lupus erythematosus (SLE) patients with recurrent urinary tract infections (UTIs). A convenience sample of consecutive patients with SLE (American College of Rheumatology criteria), with recurrent UTIs (>/=3 events in the preceding 12 months), without history of central nervous system involvement, urolithiasis or preceding tuberculosis were studied. Disease activity (SLEDAI-2K), damage (SDI), lower urinary tract symptoms [Pelvic pain and Urgency/Frequency (PUF) and the Interstitial Cystitis Symptom and Problem Index (ICSPI) scales] and Autonomic Symptom Profile (ASP) were assessed. All patients underwent urological examination and urodynamic assessment with cystometry, uroflow, micturition and urethral pressure profile. Ten patients (nine women) were included. The majority of the patients reported urinary symptoms: urgency (n = 8), frequency (n = 8), nocturia (n = 9) and pain (n = 10). The patients had a mean (SD) ICSPI score of 18.4 (9.8), PUF score of 17.4 (5.3) and ASP weighted score of 31.7 (16.1). Abnormal urodynamics findings were identified in seven of the 10 patients, including small bladder capacity (two patients), reduced bladder sensation (four patients), subnormal urinary flow rate (one patient) and a significant amount of residual urine (two patients). The urodynamics findings suggest that bladder dysfunction could be one of the mechanisms involved on the occurrence of recurrent UTIs in patients with SLE. These findings have potential implications for the proper assessment and management of SLE patients with recurrent UTIs. Further studies are needed to corroborate our results.

Obstructive uropathy as the only manifestation of flare in a patient with systemic lupus erythematosus and anti-phospholipid syndrome

Chronic interstitial cystitis and ureteral stenosis has occasionally been reported in systemic lupus erythematosus, mostly associated with gastrointestinal symptoms. We report a case of obstructive uropathy associated to chronic interstitial cystitis as the only manifestation of lupus flare in a patient with SLE and anti-phospholipid syndrome (APS) who had been in remission for many years. The development of chronic interstitial cystitis in patients with SLE and APS has not been previously reported. Histopathological study of her urinary bladder and ureteral meatus showed chronic inflammatory infiltrate in the subepithelium. Lack of significant lower urinary tract symptoms and gastrointestinal involvement were some of the factors that could have prevented an earlier diagnosis. Obstructive uropathy and renal insufficiency initially improved with immunosuppressive treatment and endoureteral protheses, but poor compliance to the therapy led to ominous ending.

Two cases of lupus cystitis with no bladder irritation symptoms

Lupus cystitis is a rare manifestation in systemic lupus erythematosus (SLE); it usually occurs in association with gastrointestinal manifestations. We report two cases of lupus cystitis without bladder irritation symptoms. Both cases developed severe abdominal pain, nausea, and diarrhea and showed no bladder irritation symptoms. The diagnosis of lupus cystitis was made by abdominal ultrasonography and bladder biopsy. The patients were treated with intravenous methylprednisolone pulse therapy followed by oral prednisolone. Their symptoms were ameliorated, and hydroureteronephrosis improved. Thus, when a patient with SLE shows gastrointestinal symptoms, further examinations are required to determine whether the patient has lupus cystitis.

Autoimmune disorders: gastrointestinal manifestations and endoscopic findings

The gastrointestinal tract can be involved in many autoimmune disorders, and women are affected more than men in most of the disease processes discussed. As this article outlines, gastrointestinal manifestations can be either part of the clinical presentation or complications of treatment. Depending on the disease process and the severity of symptoms, gastrointestinal evaluation and treatment can have an important role in the management of these diseases.

Severe interstitial cystitis associated with Sjögren's syndrome

A 53-year-old woman presented with oliguria, urinary frequency, abdominal pain and severe edema of the lower extremities. Her serum creatinine was 8.1 mg/dl. Computed tomographic and ultrasonographic studies showed a severely dilated urinary bladder, and bilateral hydroureteronephrosis. Examination of a urinary bladder biopsy specimen showed subepithelial edema and infiltration by lymphocytes and plasmacytes. However, the patient complainted of dry mouth and dry eyes. Ophthalmologically, the Schirmer test was positive. A biopsy of the minor salivary glands in the lip showed chronic sialoadenitis. A diagnosis of Sjögren's syndrome complicated by interstitial cystitis was made. Since she had been anuric, secondary to urinary obstruction, intermittent self-catheterization was started. Combination of corticosteroid and cyclosporin therapy was initiated. Spontaneous urination began, and gradually the patient's symptoms remitted. After 8 months of therapy, bladder capacity increased from 140 ml to 350 ml, and she voided approximately 1,200 ml by herself and 600 ml by catheterization daily. This case suggests that when severe interstitial cystitis is associated with Sjögren's syndrome, a therapeutic trial of corticosteroids and cyclosporin may be beneficial.

Voiding dysfunction in women with systemic lupus erythematosus

OBJECTIVE

We sought to explore bladder dysfunction in a cohort of women with systemic lupus erythematosus (SLE).

METHODS

We conducted a prospective study of 152 female patients with SLE during a 15-month period. The clinical status of SLE was determined according to the SLE Disease Activity Index (SLEDAI), and bladder function was evaluated by lower urinary tract symptoms and urodynamic studies. We adapted the American Urological Association (AUA) index questionnaire to assess lower urinary tract symptoms in patients, which were compared with those in 227 age-matched healthy women.

RESULTS

The proportion of individuals reporting urinary frequency, urgency, weak urinary stream, and incomplete emptying, as well as severe lower urinary tract symptoms (AUA index score >/=20), was significantly higher in the SLE group when compared with the control group. The AUA index score showed a modest correlation with the SLEDAI score (r = 0.35, P < 0.001) but not with patient age or disease duration. There was a significant relationship between central nervous system involvement and the AUA index score. The most common urodynamic finding was a small cystometric bladder capacity (<150 ml; n = 7 patients), followed by a subnormal urinary flow rate (<12 ml/second; n = 6 patients). In 3 of 7 patients with small cystometric bladder capacities, imaging studies documented a contracted bladder with marked hydroureteronephrosis.

CONCLUSION

Patients with SLE experience an increased prevalence of voiding dysfunction compared with healthy individuals. Voiding dysfunction can be attributable to either direct bladder involvement or other disease-related factors.

Interstitial cystitis: the painful bladder syndrome

Interstitial cystitis (IC) is an enigmatic and frustrating condition to manage as a physician and to cope with as a patient. Many patients are declared as drug addicted and neurotic. Social status and number of sexual partners showed no correlation with incidence. Patients report moderate to excruciating pain in the suprapubic or vaginal area, urgency and frequency (up to 50 micturitions/d), and disruption of their social life. Diagnosis of IC is made by exclusion. Different pathophysiologic mechanisms have been proposed: changes in epithelial permeability, pelvic floor dysfunction, mastocytosis, activation of c-fibers, and increase of nerve growth factors and bradykinin. No single theory can explain IC.

Anetoderma in systemic lupus erythematosus: relationship to antiphospholipid antibodies

Anetoderma is an elastolytic disorder where multiple patches of slack skin are formed. Twelve patients with anetoderma associated with systemic lupus erythematous have been described, all in the dermatological literature. Recently, a role for antiphospholipid antibodies has been proposed with microthromboses as its pathogenic mechanism. We present herein a 20-year-old female patient who developed anetoderma soon after sun exposure. She was found to have a false positive VDRL and gradually developed other manifestations of SLE, including interstitial cystitis. She has had repeatedly positive antiphospholipid antibodies. Although there are patients who may have a primary form, diagnosis of anetoderma should trigger a search for SLE and/or antiphospholipid antibodies.

Urinary bladder involvement in patients with systemic lupus erythematosus: with review of the literature

OBJECTIVES

To investigate the etiologies of urinary bladder involvement in patients with systemic lupus erythematosus (SLE), the clinicoradiologic features of gastrointestinal tract manifestations and clinical outcomes in patients with lupus cystitis accompanied by gastrointestinal manifestations.

METHODS

We conducted a retrospective chart review on 413 patients with SLE. Patients were selected for review on the basis of lower urinary tract symptoms including urinary frequency, urgency and urinary incontinence. Radiologic studies were analyzed in patients with lupus cystitis.

RESULTS

Ten consecutive patients, complicated with lower urinary tract symptoms, were identified. Underlying etiologies were as follows: lupus cystitis in five, neurogenic dysfunction secondary to transverse myelitis in three, cyclophosphamide-induced cystitis in one and tuberculous cystitis in one patient. All patients with lupus cystitis showed gastrointestinal manifestations, such as abdominal pain, nausea, vomiting and/or diarrhea during the periods of cystitis symptoms. In all patients with lupus cystitis, paralytic ileus was demonstrated on plain abdominal X-ray and ascites, bilateral hydroureteronephrosis and thickened bladder wall were identified on abdominal ultrasound or CT. Abdominal CT revealed bowel wall thickening in four of the five patients. The main sites of thickened bowel on abdominal CT were territory supplied by superior mesenteric artery. Two of five patients with lupus cystitis expired during the follow-up period.

CONCLUSION

Diverse etiologies may cause lower urinary tract symptoms in patients with SLE. Lupus cystitis is strongly associated with gastrointestinal involvement and abdominal CT can be a useful radiologic tool to investigate the gastrointestinal tract involvement in patients with lupus cystitis.

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.

Interstitial cystitis: unexplained associations with other chronic disease and pain syndromes

OBJECTIVE

To determine the prevalence of concomitant disease in individuals with interstitial cystitis and to compare these results to the general population.

METHODS

We used a questionnaire-based study evaluating 12 disease processes and a survey of interstitial cystitis characteristics. The population was 2,405 individuals with interstitial cystitis who responded to the initial survey and an additional 277 individuals who were randomly selected and individually contacted.

RESULTS

Allergies, irritable bowel syndrome, and sensitive skin were the most common diseases in the interstitial cystitis population. In comparison to the general population, individuals with interstitial cystitis are 100 times more likely to have inflammatory bowel disease and 30 times more likely to have systemic lupus erythematosus. In addition, allergies, irritable bowel syndrome, sensitive skin, and fibromyalgia have an increased association with interstitial cystitis.

CONCLUSIONS

Interstitial cystitis has, as yet, an unexplained association with certain other chronic disease and pain syndromes.

A case of polyarteritis nodosa with bilateral ureteral obstruction

We report a case of bilateral ureteral obstruction most likely caused by polyarteritis nodosa. The diagnosis was based upon muscle biopsy which showed typical necrotizing vasculitis in medium size artery in conjunction with microaneurysms in renal angiography. Ureteral obstruction is a rare manifestation of polyarteritis nodosa. This condition is thought to result from vasculitis of periureteral vessels. The patient was managed with prednisolone alone, which resulted in complete resolution of ureteral obstruction on both sides.

Immunofluorescent and histochemical staining confirm the identification of the many diseases called interstitial cystitis

Interstitial cystitis comprises a complex of diseases typified by symptoms of pelvic pain. Functional complaints do not aid the clinician in determining loss of anatomical capacity. Histochemical staining with PAS-colloidal iron/Van Geison's counterstain offers improved diagnostic ability for the pathologist and correlates well with immunofluorescent findings. Four distinct diseases can be identified through immunofluorescent staining, indicating that each is the result of different responses of the urothelium and endothelium to injury. Loss of bladder capacity associated with these diseases can be expected with age, but immunofluorescent staining for IgM within the capillaries of the interstitium is a more sensitive predictor.

Simultaneous occurrence of systemic lupus erythematosus and coeliac disease-like features

Involvement of the gastrointestinal tract in systemic lupus erythematosus is well documented but small intestinal malabsorption is a rare event. We report a 27 year old woman with systemic lupus erythematosus who had malabsorption and coeliac-like changes on intestinal biopsy. This is the eighth reported case of this association the significance of which is discussed.

Immunoglobulin deposits in bladder epithelium and vessels in interstitial cystitis: possible relationship to circulating anti-intermediate filament autoantibodies

Sera from patients suffering from interstitial cystitis (IC) reacted with bright staining of the bladder epithelium and vascular endothelium when tested for autoantibodies by indirect immunofluorescence using normal bladder tissue as target antigen. When tested for autoantibodies using cultured cells as antigen the antibodies were found to be directed against cytoskeletal intermediate filaments (IMF). Sera from 43 IC patients had a high incidence and high titers of anti-IMF autoantibodies as compared to both healthy individuals and patients suffering from other urological or surgical diseases. The results suggest that anti-IMF autoantibodies may be involved in the perpetuating chronic type of tissue injury seen in these patients. The antibodies were of the IgM class. In vivo deposits of IgM in patient bladder biopsies localized similarly to the autoantibodies; epithelial tissue showed deposits in 19% and vascular tissue, deposits in more than 50% of the patients, often together with complement components Clq,C3, or C4. In addition, subendothelial deposits associated with fibrillar structures could be observed. The results suggest a possible relationship between the in vivo IgM deposits in the bladder epithelium and vascular endothelium, on one hand, and the presence of anti-IMF antibodies capable of reacting with these cell structures, on the other hand. However, as the autoantibodies have to gain access to intracellular structures in order to cause in vivo deposits, primary tissue injury has to be postulated.

Successful treatment of lupus erythematosus cystitis with DMSO

Systemic lupus erythematosus patients sometimes present with pathologically confirmed lupus interstitial cystitis. Treatment with prednisone has not been observed to be successful. Two patients are presented who were successfully treated with intravesical dimethyl sulfoxide (DMSO).

Fine-structural evidence for vascular injury in patients with interstitial cystitis

Bladder vessel walls of 20 patients with interstitial cystitis were studied by the electron microscope. 14 (70%) had severe endothelial injury. 10 (50%) showed injured smooth muscle cells. Odd basement membrane proliferations and disruptions were seen. Clusters of microfibrils about 10 nm in diameter and numerous partially membrane-bound vesicles of 100-600 nm with granular or tiny vesicular content ("granulovesicular bodies") were also seen. Intercellular junctions of endothelial cells were open and there was emigration of polymorphonuclear leucocytes and platelets. The findings show pronounced vascular injury to have taken place, with neoformation of elastic tissue. It is suggested that the injury is immunologically mediated and that particularly those clusters of connective tissue microfibrils not yet covered by an amorphous elastin component may be involved in the pathogenesis of this disease.