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Zhang D, Lai J, Su G, Zhu J, Min, Kang, Li M, Xu Y, Meng L. Children systemic lupus erythematosus-associated pancreatitis. Arthritis Res Ther 2024; 26:28. [PMID: 38233944 PMCID: PMC10792798 DOI: 10.1186/s13075-024-03265-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/09/2024] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVE To early recognise and improve the prognosis of children systemic lupus erythematosus (cSLE)-associated pancreatitis by summarising and analysing clinical features and prognosis data from 12 cases. METHODS Retrospective analysis of clinical data from 12 cases of cSLE-associated pancreatitis diagnosed and treated from January 2016 to December 2021 at hospitals such as Children's Hospital of Capital Institute of Paediatrics. RESULTS The median SLEDAI-2K score for disease activity was 18.00 (range 12.25-21.00) in the case group and 10.00 (range 7.00-18.00) in the control group, with a statistically significant difference (P < 0.05) between the two groups. The case group had a higher proportion of abdominal pain, vomiting, abdominal distension, pleural effusion, Raynaud's phenomenon (RP), splenic infarction, and concurrent macrophage activation syndrome (MAS) than the control group, with a statistically significant difference (P < 0.05). Serum ferritin (SF), alanine transaminase (ALT), aspartate transaminase (AST), lactate dehydrogenase (LDH), amylase, and increased 24-h urine protein levels were statistically different between the two groups (P < 0.05); platelet counts (PLT) reduction was also statistically different (P < 0.05). The case group had a higher proportion of methylprednisolone pulse therapy, cyclophosphamide pulse therapy during remission induction, and therapeutic plasma exchange than the control group, with a statistically significant difference (P < 0.05) between the two. CONCLUSION CSLE-associated pancreatitis has a high fatality rate. The presence of RP, splenic infarction, pleural effusion, and MAS warrants attention from clinicians regarding the possibility of pancreatitis. Once pancreatitis is detected, the primary disease needs active treatment for better prognosis.
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Affiliation(s)
- Dan Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Capital Institute of Paediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Jianming Lai
- Department of Rheumatology and Immunology, Children's Hospital of Capital Institute of Paediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China.
| | - Gaixiu Su
- Department of Rheumatology and Immunology, Children's Hospital of Capital Institute of Paediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Jia Zhu
- Department of Rheumatology and Immunology, Children's Hospital of Capital Institute of Paediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | | | - Kang
- Department of Rheumatology and Immunology, Children's Hospital of Capital Institute of Paediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Ming Li
- Department of Rheumatology and Immunology, Children's Hospital of Capital Institute of Paediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Yingjie Xu
- Department of Rheumatology and Immunology, Children's Hospital of Capital Institute of Paediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Li Meng
- Department of Internal Medicine, Children's Hospital of Capital Institute of Paediatrics, Beijing, China
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Kirkpatrick KV, Nocton JJ. Unusual Presentations of Systemic Lupus Erythematosus. Med Clin North Am 2024; 108:43-57. [PMID: 37951655 DOI: 10.1016/j.mcna.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Systemic lupus erythematosus (SLE) often develops during adolescence, may affect any organ system, and may present with a wide variety of signs and symptoms. It is critical to recognize the unusual manifestations of SLE in order to make a prompt diagnosis. Earlier diagnosis allows for appropriate treatment and ultimately decreases morbidity and mortality.
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Affiliation(s)
- Kaitlin V Kirkpatrick
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA
| | - James J Nocton
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA.
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3
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Hu Y, Yuan J, Wang B, Ma L, Zha Y. Efficacy of belimumab for severe childhood-onset systemic lupus erythematosus with diffuse proliferative glomerulonephritis: A case report. Medicine (Baltimore) 2023; 102:e34800. [PMID: 37653777 PMCID: PMC10470770 DOI: 10.1097/md.0000000000034800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/27/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Therapy of childhood-onset systemic lupus erythematosus (cSLE) with drugs is unsatisfactory. Some new drugs such as belimumab and rituximab may improve the course of severe cSLE, although there are few reports on treatment efficiency for these new drugs, especially belimumab. CASE PRESENTATION Here we report on a 16-year-old girl who was diagnosed with cSLE at the age of 13. After several immunosuppressive treatments, which included high-dose steroids, hydroxychloroquine sulfate, cyclophosphamide, etc for blood system damage, she showed little clinical improvement and developed severe pericarditis. Induction treatment with a combination of intravenous high-dose steroids, methylprednisolone, and cyclophosphamide was started, but, after 55 days, the patient developed lupus encephalopathy, lung infection, and lupus nephritis. After using high-dose steroids, cyclophosphamide, plasma exchange, gamma globulin, and appropriate anti-pulmonary inflammation drugs, treatment with tacrolimus was attempted but poorly tolerated by the patient and withdrawn. Eventually, in December 2019, belimumab was initiated on an off-label basis as a last resource to treat lupus nephritis. Belimumab was well tolerated by the patient and resulted in a rapid and marked improvement in clinical symptoms and reduction in proteinuria, serum complement levels and anti-double strand DNA antibodies titer; of note, the patient developed no infectious complications. CONCLUSION Treatment with belimumab could result in prompt remission of severe cSLE with multiple organ damage without the pulmonary infection side effects for children deemed intolerant to conventional and second-line induction therapies. Belimumab should be considered as a potentially efficacious treatment in patients in severe childhood-onset systemic lupus erythematosus.
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Affiliation(s)
- Ying Hu
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Jing Yuan
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
| | - Bo Wang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Liang Ma
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Yan Zha
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
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Mauro A, Giani T, Di Mari C, Sandini M, Talenti A, Ansuini V, Biondi L, Di Nardo G, Bernardo L. Gastrointestinal Involvement in Children with Systemic Lupus Erythematosus. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020309. [PMID: 36832440 PMCID: PMC9955206 DOI: 10.3390/children10020309] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/05/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder. When it presents before the age of 18 years (childhood-onset systemic lupus erythematosus, cSLE), the disease course tends to be more severe with a higher rate of organ involvement and requires an early diagnosis. Gastrointestinal involvement in cSLE is rare and scarcely reported in the literature. Any organ of the gastrointestinal system may be affected, either as a direct consequence of the disease, as a subsequent complication, or as an adverse drug event. Abdominal pain is the most common GI symptom, it can be diffuse or well localized, and can underline different conditions such as hepatitis, pancreatitis, appendicitis, peritonitis, or enteritis. cSLE may have an alteration of the intestinal barrier with features of protein-losing enteropathy or, in genetically predisposed patients, may develop associated autoimmune disorders such as Coeliac Disease or Autoimmune Hepatitis. The aim of this manuscript is to provide a narrative review of gastrointestinal manifestations in cSLE focused on hepatic, pancreatic, and intestinal involvement. A comprehensive literature search based on the PubMed database was performed.
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Affiliation(s)
- Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Teresa Giani
- Department of Pediatrics, Meyer Children's Hospital, 50139 Firenze, Italy
| | - Clelia Di Mari
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Martina Sandini
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Antonella Talenti
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Valentina Ansuini
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Luigi Biondi
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
| | - Giovanni Di Nardo
- Faculty of Medicine and Psycology, Sapienza University of Rome-NESMOS Department, Sant'Andrea University Hospital, Via Grottarossa 1035-1039, 00189 Roma, Italy
| | - Luca Bernardo
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milano, Italy
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Muacevic A, Adler JR, Ihimoyan A. Azathioprine-Induced Pancreatitis in a Patient With Systemic Lupus Erythematosus. Cureus 2022; 14:e32697. [PMID: 36686137 PMCID: PMC9847485 DOI: 10.7759/cureus.32697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
Acute pancreatitis is an inflammatory disorder of the pancreas and a leading gastrointestinal cause of admission in the United States. The most common causes of acute pancreatitis are gallstones and alcohol. It is rarely caused by medications. Azathioprine-induced pancreatitis is rare and is more common in patients with Crohn's Disease. In this case report, we present a rare case of azathioprine-induced pancreatitis in a 58-year-old African American patient with systemic lupus erythematosus.
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Alharbi S. Gastrointestinal Manifestations in Patients with Systemic Lupus Erythematosus. Open Access Rheumatol 2022; 14:243-253. [PMID: 36281321 PMCID: PMC9587305 DOI: 10.2147/oarrr.s384256] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder of unknown etiology. Women of childbearing age are affected approximately nine times more often than men. Its presentation and course are highly variable, ranging from mild to fulminant systemic disease. Any organ can be affected by SLE. Although less common than in other systems, such as the skin, joints, and kidneys, 40%–60% of SLE patients have gastrointestinal (GI) involvement. SLE can affect any part of the GI tract, from the mouth to the anus. GI manifestations can be caused by SLE, medication-related side effects, or non-SLE causes including infection. This article reviews the most common types of GI involvement associated with SLE.
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Affiliation(s)
- Samar Alharbi
- Department of Medicine, College of Medicine, Taibah University, Medina, Saudi Arabia,Correspondence: Samar Alharbi, Department of Medicine, College of Medicine, Taibah University, Medina, 42312-3779, Saudi Arabia, Tel +96 6553018777, Fax +96 648461172, Email
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7
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方 优, 林 海, 楼 金, 陈 洁. Recurrent abdominal pain and vomiting with elevated triglyceride and positive antinuclear antibody in a girl aged 12 years. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:917-922. [PMID: 36036131 PMCID: PMC9425857 DOI: 10.7499/j.issn.1008-8830.2203006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
A girl aged 12 years and 2 months presented with recurrent abdominal pain and vomiting for more than 2 years and arthrodynia for 3 months. She was diagnosed with recurrent acute pancreatitis with unknown causes and had been admitted multiple times. Laboratory tests showed recurrent significant increases in fasting serum triglyceride, with elevated immunoglobulin and positive antinuclear antibody. The girl was improved after symptomatic supportive treatment. The girl developed arthrodynia with movement disorders 3 months before, and proteinuria, hematuria, and positive anti-double-stranded DNA antibody were observed. The renal biopsy was performed, and the pathological examination and immunofluorescence assay suggested diffuse lupus nephritis (type Ⅳ). She was finally diagnosed with systemic lupus erythematosus (SLE), lupus nephritis (type Ⅳ), and recurrent acute pancreatitis. Pancreatitis was suspected to be highly associated with SLE. She was treated with oral hydroxychloroquine sulfate and intravenous methylprednisolone sodium succinate and cyclophosphamide. Arthrodynia was partially relieved. She was then switched to oral prednisone acetate tablets. Intravenous cyclophosphamide and pump infusion of belimumab were regularly administered. Now she had improvement in arthrodynia and still presented with proteinuria and hematuria. It is concluded that recurrent acute pancreatitis may be the first clinical presentation of SLE. For pancreatitis with unknown causes, related immunological parameters should be tested, and symptoms of the other systems should be closely monitored to avoid delaying the diagnosis.
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Ferjani M, El Euch M, Hammi Y, Sayari T, Naija O, Ben Hamida F, Turki S, Gargah T. Systemic lupus erythematosus‐related acute pancreatitis: An exceptional form with severe exocrine and endocrine pancreatitic failure in a Tunisian child. Clin Case Rep 2022; 10:e05423. [PMID: 35169471 PMCID: PMC8832166 DOI: 10.1002/ccr3.5423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 12/26/2022] Open
Abstract
Acute pancreatitis may be the first manifestation in systemic lupus erythematosus or occur during evolution. It is a rare complication, which is often associated with other visceral manifestations. Outcome is usually favorable but can be serious. We report a case of a 17‐year‐old girl with a past history of systemic lupus erythematosus who developed acute pancreatitis revealed by abdominal pain. Elevated serum amylase and lipase levels and pancreatic enlargement on tomography confirmed the diagnosis. Although high‐dose corticosteroid was prescribed, the patient died from a refractory diabetic ketoacidosis.
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Affiliation(s)
- Maryem Ferjani
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Mounira El Euch
- University of Tunis El Manar Tunis Tunisia
- Internal medicine department « A » Tunis Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01) Charles Nicolle hospital of Tunis Tunis Tunisia
| | - Yousra Hammi
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Taha Sayari
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Ouns Naija
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Fethi Ben Hamida
- University of Tunis El Manar Tunis Tunisia
- Internal medicine department « A » Tunis Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01) Charles Nicolle hospital of Tunis Tunis Tunisia
| | - Sami Turki
- University of Tunis El Manar Tunis Tunisia
- Internal medicine department « A » Tunis Tunisia
| | - Tahar Gargah
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
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9
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Prevalence of Findings in Routine Abdominal Ultrasound in Patients with Systemic Autoimmune Rheumatic Diseases and Their Impact on Therapeutic Decision Making. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12020851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with systemic autoimmune rheumatic diseases (SARD) often receive abdominal ultrasound examinations to screen for organ involvement; yet, the spectrum of findings and their clinical relevance are poorly understood. We conducted a retrospective chart review of inpatients from a rheumatological referral centre with an abdominal ultrasound between 1 January2006 and 31 December 2015, examining 1092 SARD patients with a total of 1695 inpatient stays. The mean age was 55.1 years (range: 17–90 years, SD: 15.8), and the mean disease duration was 6.4 years (range: 0.0–52.8 years, SD: 9.1). A total of 87.5% of the patients were female. The most frequent ultrasound findings were hepatic steatosis (in 26.8% of all patients), splenomegaly (15.2% of all patients), pancreatic lipomatosis (14.3% of all patients) and aortic sclerosis (13.9% of all patients). Based on glucocorticoid and disease-modifying antirheumatic drug use, we identified cases where immuno-modulatory medication was escalated; there was an association between therapy escalation and the findings of hepatomegaly and pleural effusion (as tested via Fisher’s exact test). In patients with several examinations during the defined time span (n = 318), we found ultrasound findings to change, especially findings of hepatomegaly, pleural effusion and splenomegaly. When justifying decisions regarding the further treatment of a patient in the discharge letter, abdominal ultrasound results were rarely discussed. Abdominal ultrasound rarely yielded disease-specific or treatment-changing results.
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10
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Leone P, Prete M, Malerba E, Bray A, Susca N, Ingravallo G, Racanelli V. Lupus Vasculitis: An Overview. Biomedicines 2021; 9:biomedicines9111626. [PMID: 34829857 PMCID: PMC8615745 DOI: 10.3390/biomedicines9111626] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/21/2022] Open
Abstract
Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.
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Affiliation(s)
- Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Marcella Prete
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Eleonora Malerba
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Antonella Bray
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Nicola Susca
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Giuseppe Ingravallo
- Section of Pathology, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy;
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
- Correspondence:
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11
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Itagaki H, Katuhiko S. Systemic lupus erythematous presenting with hemorrhagic shock caused by gastric penetration of pancreatic pseudocyst: a case report. J Med Case Rep 2021; 15:460. [PMID: 34535187 PMCID: PMC8449441 DOI: 10.1186/s13256-021-03074-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic lupus erythematous that causes various organ damage is rarely associated with pancreatic lesion. To the best of our knowledge, no cases presenting with hemorrhage shock caused by gastric penetration of pancreatic pseudocyst due to lupus pancreatitis have been reported. Herein, we report a case of hemorrhage shock caused by gastric penetration of pancreatic pseudocyst due to lupus pancreatitis. CASE PRESENTATION A 53-year-old Japanese man with a history of systemic lupus erythematous, pancreatic pseudocyst, and chronic pancreatitis complained of epigastric pain and had hematemesis. He visited our emergency room and was admitted in our hospital. Upper endoscopy showed that hemostasis was obtained; however, computed tomography scan was performed since he was suspected to have gastric penetration into hollow viscera. The computed tomography revealed accumulation of fluid around the pancreas and gastric penetration of pancreatic cyst. Blood test showed increased serum amylase level. These results suggest that the exacerbation of chronic pancreatitis causes the penetration. Surgery was considered; however, we took a wait-and-see approach since hemostasis was obtained. After that, he was in stable condition, although he suffered from fever and accumulation of left pleural effusion was observed by computed tomography. However, he had massive hematemesis and melena 9 days after hospitalization and died in spite of several treatments including blood transfusion. Autopsy revealed that he actually had pleural thickening, which is not caused by accumulation of left pleural effusion but by severe pleural inflammation. We therefore performed additional blood and urinary tests on the same day. The test results showed that he had a high titer of anti-double-stranded deoxyribonucleic acid (DNA) antibody, hypocomplementemia, and erythrocyturia, indicating that he had systemic lupus erythematous with high disease activity considering his fever and pleural inflammation. CONCLUSIONS Patients who have systemic lupus erythematous with high disease activity have the potential to develop fatal complications due to pancreatitis, so appropriate treatments are required for such patients.
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Affiliation(s)
- Hideya Itagaki
- Department of General Surgery, Honjoudaiichi Hospital, 110, Iwabuchishita, Yurihonnjou, Akita, 015-8567, Japan.
| | - Suzuki Katuhiko
- Department of General Surgery, Honjoudaiichi Hospital, 110, Iwabuchishita, Yurihonnjou, Akita, 015-8567, Japan
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12
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Rim D, Kaye A, Choi C, Ahlawat S. Inpatient Outcomes of Acute Pancreatitis Among Patients With Systemic Lupus Erythematosus: A Nationwide Analysis. Cureus 2021; 13:e16349. [PMID: 34306896 PMCID: PMC8279928 DOI: 10.7759/cureus.16349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/20/2022] Open
Abstract
Objectives This study explores the characteristics and outcomes, including inpatient mortality, length of stay, and pancreatitis complications in patients hospitalized with acute pancreatitis (AP) with coexisting systemic lupus erythematosus (SLE). Methods Patients hospitalized with AP from the National Inpatient Sample from 2014 were selected. Patient characteristics and outcomes of AP were compared between the groups with and without SLE. Age, sex, race, Elixhauser Comorbidity Index (ECI), and etiologies of pancreatitis were measured. The outcomes of interest were inpatient mortality, length of stay, and complications, including respiratory failure, acute renal failure, myocardial infarction, hypotensive shock, sepsis, stroke, and ileus. Chi-squared tests and independent t-tests were used to compare proportions and means, respectively. Multivariate logistic regression analysis was performed to determine if SLE is an independent predictor for the outcomes, adjusting for age, sex, race, ECI, and etiologies of pancreatitis. Results Among 434,280 AP patients identified in the study, 3,015 patients had SLE. Among patients hospitalized with AP, those with SLE were younger, more likely to be female, more likely to be non-White, had higher ECI, and stayed longer in the hospital. Patients without SLE were more likely to have a history of cholelithiasis, alcohol abuse, and hypertriglyceridemia. AP patients presenting with SLE were at higher risk for respiratory failure, acute renal failure, hypotensive shock, stroke, and sepsis. Higher inpatient mortality was also associated with coexisting SLE. Conclusions Patients admitted for AP with SLE have worse outcomes compared to those without SLE. Understanding the potential effects of SLE on AP and optimizing patient care in this population accordingly may improve the quality of care and outcomes.
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Affiliation(s)
- Daniel Rim
- Internal Medicine, Rutgers University, Newark, USA
| | | | | | - Sushil Ahlawat
- Gastroenterology and Hepatology, Rutgers University, Newark, USA
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Frittoli RB, Vivaldo JF, Costallat LTL, Appenzeller S. Gastrointestinal involvement in systemic lupus erythematosus: A systematic review. J Transl Autoimmun 2021; 4:100106. [PMID: 34179742 PMCID: PMC8214088 DOI: 10.1016/j.jtauto.2021.100106] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Gastrointestinal involvement is a common complain observed in 40-60% of systemic lupus erythematosus (SLE) patients. We performed a systematic review of clinically severe and potential life-threatening gastrointestinal manifestations and discuss clinical presentation, pathogenesis and treatment. METHODS We performed a literature search in English literature using PubMed and Embase from 2000 to December 2020. The following MeSH terms: systemic lupus erythematosus, protein-losing enteropathy, ascites, pancreatitis, vasculitis, intestinal vasculitis, enteritis and diarrhea published in the English literature. RESULTS We identified 141 studies (case reports, case series and cohort studies). The most frequent presenting symptoms are acute abdominal pain, nausea, and vomiting. Many of the manifestations were associated with disease activity. Histological features are rarely available, but both vasculitis and thrombosis have been described. There is no treatment guideline. The majority of patients were treated with corticosteroids and the most common immunososupressant were azathioprine, cyclophosphamide and mycophenolate. CONCLUSION Vasculitis and thrombosis may be responsible for severe life-threatening manifestations such as pancreatitis, protein loosing gastroenteritis, acalculous cholecistyitis and enteritis.
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Affiliation(s)
- Renan Bazuco Frittoli
- Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil
| | - Jéssica Fernandes Vivaldo
- Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
| | - Lilian Tereza Lavras Costallat
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil
| | - Simone Appenzeller
- Department of Medicine, School of Medical Science - State University of Campinas, Campinas, São Paulo, 13083881, Brazil
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil
- Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil
- Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
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Muhammed H, Jain A, Irfan M, Charles S, Dwivedi P, Chavan PP, Khubchandani R, Sharma A, Phatak S, Shukla AN, Shah R, Subramanian N, Pandya SC, Singh YP, Chengappa KG, Thabah M, Rajasekhar L, Shobha V, Negi VS, Dhir V, Sharma A, Misra R, Aggarwal A. Clinical features, severity and outcome of acute pancreatitis in systemic lupus erythematosus. Rheumatol Int 2021; 42:1363-1371. [PMID: 33723658 DOI: 10.1007/s00296-021-04834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis (AP) is a rare but life threatening manifestation of Systemic Lupus Erythematosus (SLE). The current study aims to study the clinical characteristics, severity, mortality, and outcome of SLE-related AP in Indian population. We retrospectively reviewed medical records of patients with SLE who had AP in the past. Data from 13 rheumatology centers across India were compiled. All patients satisfied SLICC criteria for SLE and ATLANTA criteria for AP. AP was classified in to mild, moderate and severe using revised Atlanta classification. Patients with known risk factors like gall stone and alcohol were excluded.Sixty-six patients (six, children) were studied. Majority of patients were females (82%). The median age of presentation was 24 (11-63) years and most patients (57.5%) presented within first year of diagnosis of lupus. AP occurred mostly in the setting of active lupus (89%). Active nephritis was seen in 39% while a fourth had CNS disease. Patients with severe AP had lower C3. Ascites and sepsis were most common local and systemic complications, respectively. Mortality was 17%. Hypocalcemia, presence of sepsis and shock predicted mortality. In the multivariate analysis, only presence of shock remained as independent predictor of death (OR 63.0, 95% CI: 5.2-760.3). Pancreatitis is an early manifestation of SLE and is associated with active disease. Significant mortality is seen particularly with severe pancreatitis.
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Affiliation(s)
- Hafis Muhammed
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Avinash Jain
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.,Currently SMS Medical College and Hospital, Jaipur, India
| | | | - Sheba Charles
- St John's National Academy of Medical College, Bengaluru, India
| | - Preksha Dwivedi
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | | | | | - Ripal Shah
- One-Centre for Rheumatology and Genetics, Vadodara, India
| | | | | | | | - K G Chengappa
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Molly Thabah
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | - Vineeta Shobha
- St John's National Academy of Medical College, Bengaluru, India
| | - V S Negi
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Varun Dhir
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramnath Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
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Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a complex autoimmune pathology that can involve any organ. Lupus-related acute pancreatitis (AP) is, together with lupus mesenteric vasculitis, an important cause of SLE-induced acute abdominal pain. METHODS A literature search was conducted using the terms "Pancreatitis" and "Lupus Erythematosus, Systemic" on PubMed/Medline and Web of Science from January 2007 to January 2020. Clinical characteristics, diagnostic approach, and treatment principles in SLE-related AP are presented in this review. RESULTS Mainly retrospective reports were identified. The reported incidence of SLE-associated AP ranges from 0.9 to more than 5% of patients. A total of 264 SLE patients were found in the selected research, with a net female predominance (sex ratio 9:1) and mean age of 31.4 years. Abdominal pain was virtually present in all cases. AP occurrence was more frequent in SLE patients with short disease duration, high activity scores, and multiorgan involvement. The AP definition was based on currently available guidelines and after exclusion of any other known causes (including iatrogenic, i.e. drugs), a diagnosis of "idiopathic" SLE-related AP might be sustained. Management is difficult, as there is no standardized therapeutic approach. Of note, glucocorticoid use remains still controversial as, especially for high doses, subsequent pancreatic injury may occur. Monitoring serum lipase levels after high dose steroids might be considered. One study reported beneficial prognostic effect of plasma exchange. Moreover, AP in SLE might raise awareness about macrophage activation syndrome association. Mortality up to one third of AP cases in SLE was reported. CONCLUSION The SLE-related AP is a rare, but severe, life-threatening complication. Corticosteroids must be used with caution. Plasma exchange could be considered in selected cases.
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Affiliation(s)
- Alina Dima
- Rheumatology Department, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Daniel Vasile Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Dr Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - Ciprian Jurcut
- Second Internal Medicine Department, Dr Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Dr Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
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Paleti S, Yarlagadda B, Gremida A, Aziz M, Hanson J, McCarthy D. Colitis and Pancreatitis in a Patient with Systemic Lupus Erythematosus: Due to Disease or to Drug? Dig Dis Sci 2018; 63:2206-2209. [PMID: 30069857 DOI: 10.1007/s10620-018-5225-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC10-5550, Albuquerque, NM, 87131, USA.
| | - Bharath Yarlagadda
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Anas Gremida
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC10-5550, Albuquerque, NM, 87131, USA
| | - Muhammad Aziz
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Joshua Hanson
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Denis McCarthy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC10-5550, Albuquerque, NM, 87131, USA
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17
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Gayam V, Mandal AK, Khalid M, Kaler J, Thapa S, Garlapati P, Gill A, Alex R, Shrestha B. A Rare Case of Systemic Lupus Erythematosus with Gastric Ulcer and Acute Pancreatitis: A Case Report and Literature Review. Gastroenterology Res 2018; 11:321-325. [PMID: 30116433 PMCID: PMC6089583 DOI: 10.14740/gr1048w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/17/2018] [Indexed: 12/31/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease which can manifest in many different organ systems. Gastrointestinal (GI) involvement is common in SLE, but the symptoms are usually mild. More severe GI complications including acute pancreatitis and peptic ulcer bleeding are rare but represent a significant risk of morbidity and mortality. We present a case of a 25-year-old Hispanic female with a severe SLE flare. The initial presentation included symptoms of hematemesis and epigastric abdominal pain secondary to both gastric ulceration and acute pancreatitis, an atypical presentation of an SLE flare. The non-specific symptom of abdominal pain makes both acute pancreatitis and gastric ulcer disease a clinical challenge; however, clinicians need to have a high suspicion for these conditions co-existing at the same time due to higher mortality rates.
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Affiliation(s)
- Vijay Gayam
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | | | - Mazin Khalid
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Jaspreet Kaler
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Shivani Thapa
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Pavani Garlapati
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Arshpal Gill
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Ragin Alex
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Binav Shrestha
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
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18
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A Rare Case of Lupus Pancreatitis Disguised as Gallstone Pancreatitis. J Clin Rheumatol 2017; 23:346-347. [DOI: 10.1097/rhu.0000000000000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Li Z, Xu D, Wang Z, Wang Y, Zhang S, Li M, Zeng X. Gastrointestinal system involvement in systemic lupus erythematosus. Lupus 2017; 26:1127-1138. [PMID: 28523968 DOI: 10.1177/0961203317707825] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem disorder which can affect the gastrointestinal (GI) system. Although GI symptoms can manifest in 50% of patients with SLE, these have barely been reviewed due to difficulty in identifying different causes. This study aims to clarify clinical characteristics, diagnosis and treatment of the four major SLE-related GI system complications: protein-losing enteropathy (PLE), intestinal pseudo-obstruction (IPO), hepatic involvement and pancreatitis. It is a systematic review using MEDLINE and EMBASE databases and the major search terms were SLE, PLE, IPO, hepatitis and pancreatitis. A total of 125 articles were chosen for our study. SLE-related PLE was characterized by edema and hypoalbuminemia, with Technetium 99m labeled human albumin scintigraphy (99mTc HAS) and alpha-1-antitrypsin fecal clearance test commonly used as diagnostic test. The most common site of protein leakage was the small intestine and the least common site was the stomach. More than half of SLE-related IPO patients had ureterohydronephrosis, and sometimes they manifested as interstitial cystitis and hepatobiliary dilatation. Lupus hepatitis and SLE accompanied by autoimmune hepatitis (SLE-AIH overlap) shared similar clinical manifestations but had different autoantibodies and histopathological features, and positive anti-ribosome P antibody highly indicated the diagnosis of lupus hepatitis. Lupus pancreatitis was usually accompanied by high SLE activity with a relatively high mortality rate. Early diagnosis and timely intervention were crucial, and administration of corticosteroids and immunosuppressants was effective for most of the patients.
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Affiliation(s)
- Z Li
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing China
| | - D Xu
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing China
| | - Z Wang
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing China
| | - Y Wang
- 2 Department of Epidemiology and Bio-statistics, Institute of Basic Medical Sciences, China Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - S Zhang
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing China
| | - M Li
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing China
| | - X Zeng
- 1 Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing China
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Retrospective analysis of plasma exchange combined with glucocorticosteroids for the treatment of systemic lupus erythematosus-related acute pancreatitis in central China. ACTA ACUST UNITED AC 2016; 36:501-508. [DOI: 10.1007/s11596-016-1615-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/28/2016] [Indexed: 12/14/2022]
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21
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Prevalence, severity, and clinical features of acute and chronic pancreatitis in patients with systemic lupus erythematosus. Rheumatol Int 2016; 36:1413-9. [PMID: 27379762 DOI: 10.1007/s00296-016-3526-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/28/2016] [Indexed: 12/13/2022]
Abstract
Pancreatitis is a rare, life-threatening complication of systemic lupus erythematosus (SLE). This study aimed to describe the clinical features of acute pancreatitis (AP) and chronic pancreatitis (CP) in patients with SLE. Data of patients who fulfilled the revised criteria of the American Rheumatism Association for diagnosis of SLE were retrospectively analyzed. SLE activity was graded according to the SLE Disease Activity Index. Logistic regression analysis was conducted to find out independent associations. Survival rates were estimated by using Kaplan-Meier plots. This study included 5665 SLE patients admitted between January 1983 and January 2014, of whom 52 patients were diagnosed with pancreatitis. Pancreatitis prevalence in SLE patients was 0.92 % (52/5665). AP (0.8 %, 46/5665) was more prevalent than CP (0.1 %, 6/5665), presented mostly during active SLE, and affected more organs. Hypertriglyceridemia occurred in 76.9 % of AP patients and in none of the CP patients. AP patients were divided into severe (n = 10) or mild (n = 20) cases. The average triglyceride level in severe AP cases was higher than that in mild AP cases (P = 0.006), and the mortality rate of lupus-associated AP was 32.6 % (15/46). Concomitant infections and thrombocytopenia were independently associated with poor prognosis (P < 0.001, P = 0.028, respectively). There were significant differences in the clinical manifestations of AP and CP. Patients with severe AP were found to have a higher incidence of concomitant infection and serum triglyceride levels. Concomitant infections and thrombocytopenia were independent risk factors for poor prognosis.
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22
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Parperis KM, Al-Ani M. A Precarious Presentation: Systemic Lupus Erythematosus. Am J Med 2016; 129:681-4. [PMID: 27046244 DOI: 10.1016/j.amjmed.2016.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/05/2016] [Accepted: 02/23/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Konstantinos M Parperis
- Division of Rheumatology, University of Arizona College of Medicine, Phoenix; Department of Medicine, Maricopa Integrated Health System, Phoenix, Ariz
| | - Muhsen Al-Ani
- Department of Medicine, Maricopa Integrated Health System, Phoenix, Ariz; Department of Medicine, University of Arizona College of Medicine, Phoenix.
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Alves SC, Fasano S, Isenberg DA. Autoimmune gastrointestinal complications in patients with systemic lupus erythematosus: case series and literature review. Lupus 2016; 25:1509-1519. [PMID: 27329649 DOI: 10.1177/0961203316655210] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/25/2016] [Indexed: 02/06/2023]
Abstract
The association of systemic lupus erythematosus (SLE) with gastrointestinal autoimmune diseases is rare, but has been described in the literature, mostly as case reports. However, some of these diseases may be very severe, thus a correct and early diagnosis with appropriate management are fundamental. We have analysed our data from the SLE patient cohort at University College Hospital London, established in 1978, identifying those patients with an associated autoimmune gastrointestinal disease. We have also undertaken a review of the literature describing the major autoimmune gastrointestinal pathologies which may be coincident with SLE, focusing on the incidence, clinical and laboratory (particularly antibody) findings, common aetiopathogenesis and complications.
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Affiliation(s)
- S Custódio Alves
- Internal Medicine Unit, Department of Medicine, Hospital de Cascais, Cascais, Portugal
| | - S Fasano
- Rheumatology Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - D A Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
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24
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Acute Pancreatitis in Pediatric Patients: Demographics, Etiology, and Diagnostic Imaging. AJR Am J Roentgenol 2016; 206:632-44. [PMID: 26901022 DOI: 10.2214/ajr.14.14223] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this article is to provide updates on acute pancreatitis in children regarding the imaging findings, causes, and complications based on a review of the current studies in the pediatrics literature. We discuss the epidemiology of acute pancreatitis, the role of imaging and imaging findings in the diagnosis of acute pancreatitis, and the causes and complications of acute pancreatitis. CONCLUSION The incidence of acute pancreatitis is increasing in children. Imaging plays an important role in the diagnosis of acute pancreatitis because imaging findings can be used to establish the cause of acute pancreatitis, evaluate for complications of acute pancreatitis, and possibly predict the course of the disease.
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Abstract
OBJECTIVE Pancreatitis is a rare and a life-threatening systemic lupus erythematosus (SLE) manifestation in childhood-onset SLE (cSLE). The objective of this study was to systematically classify pancreatitis in cSLE according to the International Study Group of Pediatric Pancreatitis and determine the overall prevalence, clinical features, laboratory, and first episode outcomes. METHODS A multicenter cohort study in 10 pediatric rheumatology centers, including 852 patients with cSLE. RESULTS Pancreatitis was diagnosed in 22 of 852 (2.6%) patients with cSLE. It was classified as acute pancreatitis in 20 (91%), acute recurrent pancreatitis in 2 (9%), and none of them had chronic pancreatitis. None of them had gallstones, traumatic pancreatitis, or reported alcohol/tobacco use. The comparison of patients with pancreatitis (first episode) and without this complication revealed a shorter disease duration (1 [0-10] vs 4 [0-23] years, P < 0.0001) and higher median of Systemic Lupus Erythematosus Disease Activity Index 2000 (21 [0-41] vs 2 [0-45], P < 0.0001). The frequencies of fever (P < 0.0001), weight loss (P < 0.0001), serositis (P < 0.0001), nephritis (P < 0.0001), arterial hypertension (P < 0.0001), acute renal failure (P < 0.0001), macrophage activation syndrome (P < 0.0001), and death (P = 0.001) were also higher in patients with pancreatitis. The frequencies of intravenous methylprednisolone use (P < 0.0001) and the median of prednisone dose (55 [15-60] vs 11 [1-90] mg/day, P < 0.0001) were significantly higher in patients with pancreatitis. Of note, the 2 patients with acute recurrent pancreatitis had 2 episodes, with pain-free interval of 1 and 4 years. CONCLUSIONS This was the first study characterizing pancreatitis using the International Study Group of Pediatric Pancreatitis standardized definitions in patients with cSLE showing that the predominant form is acute pancreatitis seen in association with glucocorticoid treatment and active severe disease.
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Gormezano NWS, Otsuzi CI, Barros DL, da Silva MA, Pereira RMR, Campos LMA, Borba EF, Bonfá E, Silva CA. Macrophage activation syndrome: A severe and frequent manifestation of acute pancreatitis in 362 childhood-onset compared to 1830 adult-onset systemic lupus erythematosus patients. Semin Arthritis Rheum 2015; 45:706-10. [PMID: 26833399 DOI: 10.1016/j.semarthrit.2015.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/31/2015] [Accepted: 10/30/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We previously reported a case series of acute pancreatitis (AP) and macrophage activation syndrome (MAS) in childhood (cSLE) patients; however, there are no data regarding the comparison of AP and MAS in large populations of cSLE and adult SLE (aSLE). METHODS A study included 362 cSLE and 1830 aSLE patients. MAS was diagnosed according to preliminary diagnostic guidelines and AP according to the presence of abdominal pain or vomiting associated to an increase of pancreatic enzymes and/or pancreatic radiological abnormalities. Demographic data, clinical features, SLEDAI-2K, SLICC/ACR-DI, and treatment were assessed. RESULTS Age in MAS patients was significantly lower compared with those without this complication [15 (8.8-55) vs. 33.5 (10.2-45.7) years, p = 0.007]. The frequencies of fever (94% vs. 37%, p = 0.001), leucopenia (82% vs. 19%, p = 0.0001), thrombocytopenia (65% vs. 19%, p = 0.013), hypertriglyceridemia (87% vs. 42%, p = 0.037), and hyperferritinemia (93% vs. 37%, p = 0.011) were also more frequently observed in AP patients with MAS compared in AP patients without MAS. Fever and hyperferritinemia concomitantly were more frequent in the former group (86% vs. 12%, p = 0.0015). Higher and significant frequency of AP in cSLE compared to aSLE patients [12/362 (3.3%) vs. 20/1830 (1.1%), p = 0.003], with similar AP duration [22 (6-60) vs. 15 (4-90) days, p = 0.534]. MAS (85% vs. 30%, p = 0.003) and death by MAS complication (31% vs. 0%, p = 0.017) were significantly higher in children compared with aSLE. CONCLUSIONS This study provides novel data demonstrating that MAS occur in the majority of cSLE with AP with a higher mortality compared to aSLE. In addition, we identified in AP patients, a cluster of MAS clinical and laboratorial parameters more associated with this complication.
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Affiliation(s)
- Natali W S Gormezano
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil; Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carini I Otsuzi
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Diego L Barros
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Mariana A da Silva
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Rosa M R Pereira
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Lucia M A Campos
- Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo F Borba
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Eloisa Bonfá
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Clovis A Silva
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil; Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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Acute pancreatitis as the initial presentation of systematic lupus erythematosus. Case Rep Gastrointest Med 2014; 2014:571493. [PMID: 25197582 PMCID: PMC4150433 DOI: 10.1155/2014/571493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/28/2014] [Indexed: 12/26/2022] Open
Abstract
Systematic lupus erythematosus (SLE) is a multisystem disease, including the gastrointestinal system in about half of SLE patients. As a rare complication of SLE, acute pancreatitis presents as generalized flare-ups in most cases of patients previously diagnosed with SLE. Here we report a rare case of acute pancreatitis as the initial presentation with later diagnosis of SLE.
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Yuan S, Lian F, Chen D, Li H, Qiu Q, Zhan Z, Ye Y, Xu H, Liang L, Yang X. Clinical Features and Associated Factors of Abdominal Pain in Systemic Lupus Erythematosus. J Rheumatol 2013; 40:2015-22. [PMID: 24187097 DOI: 10.3899/jrheum.130492] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective.To evaluate the clinical characteristics of systemic lupus erythematosus (SLE)-induced abdominal pain in a cohort in South China and identify the risk factors for SLE-induced abdominal pain.Methods.This is a retrospective cohort study of SLE patients with complaint of abdominal pain admitted to the first affiliated university hospital of Sun Yat-sen University between 2002 and 2011. Demographic information, clinical features, laboratory findings, SLE Disease Activity Index, and imaging characteristics were documented.Results.Of the 3823 SLE patients reviewed, 213 patients complained of abdominal pain and 132 cases were considered SLE-induced. The most common causes were lupus mesenteric vasculitis (LMV; 73.5%, 97/132) and lupus pancreatitis (LP; 17.4%, 23/132). Other causes included appendicitis, acute gastroenteritis, and peritonitis. Univariate and multivariate logistic regression analysis indicated the European Consensus Lupus Activity Measurement (ECLAM) score was significantly associated with lupus-induced abdominal pain (OR = 1.858, 95% CI: 1.441–2.394, p < 0.001), LMV (OR = 1.713, 95% CI: 1.308-2.244, p < 0.001), and LP (OR = 2.153, 95% CI: 1.282, 3.617, p = 0.004). The serum D-dimer level (OR = 1.004, 95% CI: 1.002-1.005, p < 0.001) was a strongly associated factor for lupus-induced abdominal pain. Moderate and large amounts of ascetic fluid was significantly associated with lupus-induced abdominal pain and LMV. Elevated liver enzymes was a risk factor for LP (OR = 34.605, 95% CI: 3.591-333.472, p = 0.002).Conclusion.LMV and LP were the leading causes of SLE-induced abdominal pain. The serum D-dimer was a strongly associated factor for lupus-induced abdominal pain. ECLAM score was a reliable index in assessment of SLE-associated abdominal pain. Elevated liver enzymes, and moderate or large amounts of ascites, were positively associated with lupus-induced abdominal pain.
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Systemic lupus erythematosus-related pancreatitis in children. Clin Rheumatol 2013; 32:913-8. [PMID: 23673437 DOI: 10.1007/s10067-013-2242-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 03/20/2013] [Indexed: 10/26/2022]
Abstract
We report on three patients who developed four episodes of acute pancreatitis while their systemic lupus erythematosus was active and being treated with prednisolone. In all three, gastritis was first considered and treated due to abdominal pain, vomiting, and epigastric tenderness, but their symptoms did not improve. Then pancreatic enzymes were measured, which confirmed pancreatitis. Imaging studies showed an enlarged pancreas in one case, a normal pancreas in two cases, and a focal hypodense nonenhancing parenchyma in one case. Corticosteroids were prescribed for both active SLE and SLE-related pancreatitis. Pulse methylprednisolone was prescribed in one episode, increasing oral prednisolone in one episode, and the same dose of prednisolone continued in the other two episodes. All cases recovered without complications. SLE-related pancreatitis should be considered in SLE patients when the SLE is active and a patient develops abdominal pain and vomiting.
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Cichoż-Lach H, Celiński K. Lesions of alimentary tract in the course of systemic lupus erythematosus. Rheumatology (Oxford) 2013; 51:36-41. [DOI: 10.5114/reum.2013.33392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
Toczeń rumieniowaty układowy jest przewlekłą, zapalną chorobą tkanki łącznej o podłożu autoimmunologicznym, w przebiegu której mogą być zajęte różne narządy i układy. Objawy ze strony przewodu pokarmowego występują u 25–40% pacjentów z aktywną chorobą. Są one zwykle niespecyficzne i wynikają z istniejącej choroby bądź działań niepożądanych zastosowanej terapii. Zmiany w przewodzie pokarmowym mogą obejmować każdy z jego odcinków, a także dotyczyć wątroby i trzustki. W artykule przedstawiono najczęstsze i najcięższe objawy gastroenterologiczne w przebiegu tocznia rumieniowatego układowego, wśród nich toczniowe zapalenie naczyń krezki, enteropatię białkową, rozedmę pęcherzykową jelita, uszkodzenie wątroby i ostre zapalenie trzustki.
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Systemic-lupus-erythematosus-related acute pancreatitis: a cohort from South China. Clin Dev Immunol 2012; 2012:568564. [PMID: 22761631 PMCID: PMC3385924 DOI: 10.1155/2012/568564] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 04/26/2012] [Accepted: 04/29/2012] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis (AP) is a rare but life-threatening complication of SLE. The current study evaluated the clinical characteristics and risk factors for the mortality of patients with SLE-related AP in a cohort of South China. Methods. Inpatient medical records of SLE-related AP were retrospectively reviewed. Results. 27 out of 4053 SLE patients were diagnosed as SLE-related AP, with an overall prevalence of 0.67%, annual incidence of 0.56‰ and mortality of 37.04%. SLE patients with AP presented with higher SLEDAI score (21.70 ± 10.32 versus 16.17 ± 7.51, P = 0.03), more organ systems involvement (5.70 ± 1.56 versus 3.96 ± 1.15, P = 0.001), and higher mortality (37.04% versus 0, P = 0.001), compared to patients without AP. Severe AP (SAP) patients had a significant higher mortality rate compared to mild AP (MAP) (75% versus 21.05%, P = 0.014). 16 SLE-related AP patients received intensive GC treatment, 75% of them exhibited favorable prognosis. Conclusion. SLE-related AP is rare but concomitant with high mortality in South Chinese people, especially in those SAP patients. Activity of SLE, multiple-organ systems involvement may attribute to the severity and mortality of AP. Appropriate glucocorticosteroid (GC) treatment leads to better prognosis in majority of SLE patients with AP.
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Elqatni M, Mekouar F, Sekkach Y, Elomri N, Fatihi J, Amezyane T, Abouzahir A, Ghafir D. [Haemophagocytic syndrome as a complication of acute pancreatitis during systemic lupus erythematosus]. Ann Dermatol Venereol 2011; 139:46-9. [PMID: 22225742 DOI: 10.1016/j.annder.2011.10.398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 06/25/2011] [Accepted: 10/17/2011] [Indexed: 01/26/2023]
Abstract
BACKGROUND Acute pancreatitis and haemophagocytic syndrome (HS) are rarely seen in systemic lupus erythematosus (SLE). PATIENTS AND METHODS We report the case of a young female patient without any noteworthy prior history, who was hospitalised for abdominal pain associated with acute pancreatitis possibly related to SLE with associated haemophagocytic syndrome. DISCUSSION Screening for cutaneous symptoms of lupus in patients with pancreatitis can help avoid diagnostic errors.
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Affiliation(s)
- M Elqatni
- Service de médecine interne B, hôpital militaire d'instruction Mohammed V, Hay Riad, Rabat, Maroc.
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Koga T, Miyashita T, Koga M, Izumi Y, Onizuka S, Fujioka H, Fujiwara S, Nakamichi C, Nakashima K, Migita K. A case of lupus-associated pancreatitis with ruptured pseudoaneurysms. Mod Rheumatol 2011. [DOI: 10.3109/s10165-011-0415-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wang CH, Yao TC, Huang YL, Ou LS, Yeh KW, Huang JL. Acute pancreatitis in pediatric and adult-onset systemic lupus erythematosus: A comparison and review of the literature. Lupus 2011; 20:443-452. [DOI: 10.1177/0961203310387179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
This study aimed to compare differences of acute pancreatitis between adult- and pediatric-onset systemic lupus erythematosus (SLE) patients and to clarify the risk factors for mortality. Medical records that carried the dual diagnosis of SLE and acute pancreatitis between 1991 and 2005 were reviewed. Forty-eight episodes of acute pancreatitis were identified in 13 pediatric-onset SLE (pSLE) and 27 adult-onset SLE (aSLE) patients. The prevalence was 1.34% overall, with higher prevalence in pSLE (5.22%) compared with aSLE (0.99%) ( p < 0.001). The SLEDAI score on presentation of acute pancreatitis was higher in pSLE (mean ± SD: 21.77 ± 13.09) than in aSLE patients (13.37 ± 8.32) ( p = 0.05). Eleven patients died during episodes of acute pancreatitis and mortality rate was significantly higher in pSLE than in the aSLE group (53.8% and 14.8%, respectively, p = 0.015). Mortality was associated with concurrent SLE symptoms ( p = 0.049), higher SLEDAI score at presentation of acute pancreatitis ( p = 0.011), severe acute pancreatitis ( p < 0.001), and the presence of complications ( p < 0.001). The multivariate logistic regression analysis showed that severity of acute pancreatitis was the most powerful risk factor for mortality in SLE patients with this disease. In summary, our results indicate that acute pancreatitis occurs more frequently, tends to be more severe, and is associated with higher mortality in pSLE patients when compared with aSLE patient.
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Affiliation(s)
- CH Wang
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - TC Yao
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - YL Huang
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - LS Ou
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - KW Yeh
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - JL Huang
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Dhir V, Misra R, Agarwal V, Lawrence A, Aggarwal A. Lupus pancreatitis - early manifestation of active disease. Lupus 2011; 20:547-8. [PMID: 21335400 DOI: 10.1177/0961203310385165] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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A case of lupus-associated pancreatitis with ruptured pseudoaneurysms. Mod Rheumatol 2011; 21:428-31. [PMID: 21308389 DOI: 10.1007/s10165-011-0415-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 01/06/2011] [Indexed: 10/18/2022]
Abstract
Pancreatitis is a relatively rare complication in systemic lupus erythematosus (SLE). Herein we report a case of SLE with the initial development of acute pancreatitis, subsequently complicated by bleeding pseudoaneurysms. A 55-year-old Japanese woman was admitted to our hospital for the treatment of SLE. During the course of treatment, she complained of upper abdominal pain. An abdominal computed tomography (CT) scan showed that the pancreas was diffusely enlarged, and she was diagnosed with acute pancreatitis. Her pancreatitis was resistant to glucocorticoid therapy and was subsequently associated with pancreatic pseudocysts and recurrent rupture of the pseudoaneurysms. After surgical drainage of the hemorrhagic pseudocysts, the patient's clinical condition gradually improved with intensive therapies. Our case indicates that lupus pancreatitis can be associated with the potentially fatal complication of recurrent bleeding of pseudoaneurysms.
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38
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Acute hepatitis and acute pancreatitis as the presenting manifestations of SLE in a 14-year-old boy. INDIAN JOURNAL OF RHEUMATOLOGY 2010. [DOI: 10.1016/s0973-3698(11)60014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune connective tissue disease with protean manifestations. Most often it presents with mucocutaneous, musculoskeletal or renal involvement. In comparison, gastrointestinal (GI) manifestations of SLE are far less common. The case presented here highlights the differential diagnosis of GI manifestations of SLE that range from non-life-threatening to serious life-threatening complications, including some of the complications of on-going drug treatments. While some of them present as 'acute abdomen', others are more subacute or chronic, yet serious enough to be life-threatening. The serious GI manifestations of SLE include mesenteric vasculitis causing perforation or hemorrhage with peritonitis, acute pancreatitis and intestinal pseudo-obstruction. The patient in this paper had clinical features, imaging findings and laboratory parameters that helped the treating physician to narrow down the diagnostic possibilities and finally, in making the diagnosis of lupus-pancreatitis. She was treated with intravenous 'bolus' (i.v.-pulse) methylprednisolone for 3 days, i.v.-pulse cyclophosphamide 750 mg (one dose) along with oral methylprednisolone and other supportive measures including blood transfusions. This led to prompt and complete recovery.
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Affiliation(s)
- Anand N Malaviya
- Department of Rheumatology, ISIC Superspeciality Hospital, Vasant Kunj, New Delhi, India.
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40
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Hoorn EJ, Flink HJ, Kuipers EJ, Poley JW, Mensink PBF, Dolhain RJEM. Complicated systemic lupus erythematosus pancreatitis: pseudocyst, pseudoaneurysm, but real bleeding. Lupus 2010; 20:305-7. [PMID: 20956462 DOI: 10.1177/0961203310383071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report the case of a 25-year-old patient with systemic lupus erythematosus (SLE) pancreatitis which was complicated by pseudocyst and pseudoaneurysm formation. The pseudoaneurysm progressed to intra-abdominal bleeding requiring endovascular coil embolization of the gastroduodenal artery. The pseudocyst and hematoma formed two large abdominal fluid collections causing symptoms due to a mass effect. These fluid collections were treated conservatively, while active SLE was treated with steroids, azathioprine, and immunoglobulins. She finally made a full recovery. To the best of our knowledge, this is the first report of a bleeding pseudoaneurysm complicating SLE pancreatitis. Although anecdotal, this case may serve as a useful example of the possible complications of SLE pancreatitis, including considerations on optimal management.
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Affiliation(s)
- E J Hoorn
- Departments of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
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41
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Campos LMA, Omori CH, Lotito APN, Jesus AA, Porta G, Silva CAA. Acute pancreatitis in juvenile systemic lupus erythematosus: a manifestation of macrophage activation syndrome? Lupus 2010; 19:1654-8. [PMID: 20837568 DOI: 10.1177/0961203310378863] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute pancreatitis (AP) is a rare and life-threatening manifestation of juvenile systemic lupus erythematosus (JSLE). The objective of this study was to evaluate the prevalence and clinical features of AP in our JSLE population. AP was defined according to the presence of abdominal pain or vomiting associated to an increase of pancreatic enzymes and/or pancreatic radiological abnormalities. Of note, in the last 26 years, 5367 patients were followed up at our Pediatric Rheumatology Unit and 263 (4.9%) of them had JSLE diagnosis (ACR criteria). AP was observed in 4.2% (11/263) of JSLE patients. The median of age of the JSLE patients at AP diagnosis was 12.4 years (8.8-17.9). All of them had lupus disease activity at AP onset. Three patients were receiving corticosteroids before AP diagnosis. Interestingly, 10/11 JSLE patients fulfilled preliminary guidelines for macrophage activation syndrome, three of them with macrophage hemophagocytosis in bone marrow aspirate and hyperferritinemia. The hallmark of this syndrome is excessive activation and proliferation of T lymphocytes and macrophages with massive hypersecretion of proinflammatory cytokines and clinically it is characterized by the occurrence of unexplained fever, cytopenia and hyperferritinemia. AP treatment was mainly based on intravenous methylprednisolone. Four JSLE patients with AP died and two developed diabetes mellitus. In conclusion, AP was a rare and severe manifestation in active pediatric lupus. The association between AP and macrophage activation syndrome suggests that the pancreas could be a target organ of this syndrome and that pancreatic enzyme evaluation should also be carried out in all patients.
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Affiliation(s)
- L M A Campos
- Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune connective tissue disorder, with a heterogeneous presentation. Disease severity is wide ranging, with most suffering milder forms; however, it is potentially fatal depending on organ involvement. The disorder was recognized as early as the Middle Ages, with the 12th-century physician Rogerius being the first to apply the term lupus to the classic malar rash, and in 1872, Moric Kaposi first recognized the systemic nature of the disease. Perioperatively, SLE can present major challenges to the anesthesiologist because of accrued organ damage, coagulation defects, and complex management regimes. In this article I highlight adult SLE manifestations and treatments pertinent to the anesthesiologist and discuss perioperative management of these complex patients.
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43
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Tian XP, Zhang X. Gastrointestinal involvement in systemic lupus erythematosus: Insight into pathogenesis, diagnosis and treatment. World J Gastroenterol 2010; 16:2971-7. [PMID: 20572299 PMCID: PMC2890936 DOI: 10.3748/wjg.v16.i24.2971] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease characterized by the presence of a plethora of autoantibodies and immune complex formation. Virtually every system and organ can be affected by SLE. Gastrointestinal symptoms are common in SLE patients, and more than half of them are caused by adverse reactions to medications and viral or bacterial infections. Though not as common as lupus nephritis, SLE-related gastrointestinal involvement is clinically important because most cases can be life-threatening if not treated promptly. Lupus mesenteric vasculitis is the most common cause, followed by protein-losing enteropathy, intestinal pseudo-obstruction, acute pancreatitis and other rare complications such as celiac disease, inflammatory bowel diseases, etc. No specific autoantibody is identified as being associated with SLE-related gastroenteropathy. Imaging studies, particularly abdominal computed tomography scans, are helpful in diagnosing some SLE-related gastroenteropathies. Most of these complications have good therapeutic responses to corticosteroids and immunosuppressive agents. Supportive measures such as bowel rest, nutritional support, antibiotics and prokinetic medications are helpful in facilitating functional recovery and improving the outcome.
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Rose W, Puliyel MM, Moses PD, Danda D. Acute pancreatitis as the initial presentation in pediatric systemic lupus erythematosus. Indian J Pediatr 2009; 76:846-7. [PMID: 19475344 DOI: 10.1007/s12098-009-0156-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Accepted: 07/25/2008] [Indexed: 11/30/2022]
Abstract
It is exceptionally rare for acute pancreatitis to be the presenting manifestation of childhood systemic lupus erythematosus. We report a 14-year-old girl who presented with a history of fever, generalized rash, arthralgia and abdominal pain. Her serum amylase was 1472U/L and lipase 3316 U/L suggestive of acute pancreatitis. Other investigations revealed pancytopenia, low complement, high 24-hour urinary protein and elevated ANA and dsDNA. She was treated with IV methylprednisone, followed by oral steroids.
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Affiliation(s)
- Winsley Rose
- Departments of Child Health and Rheumatology and Immunology, Christian Medical College, Vellore 632004, India
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45
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Vergara-Fernandez O, Zeron-Medina J, Mendez-Probst C, Salgado-Nesme N, Borja-Cacho D, Sanchez-Guerrero J, Medina-Franco H. Acute abdominal pain in patients with systemic lupus erythematosus. J Gastrointest Surg 2009; 13:1351-7. [PMID: 19415401 DOI: 10.1007/s11605-009-0897-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 04/15/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with Systemic Lupus Erythematosus (SLE) that present with acute abdominal pain (AAP) represent a challenge for the general surgeon. The purpose of this study was to identify the major causes of AAP among these patients and to define the role of disease activity scores and the APACHE II score in identifying patients with an increased perioperative risk. METHODS We conducted a prospective study of patients admitted to the ER with AAP and SLE in an 11-year period. Demographic, diagnostic, and treatment data were recorded. Systemic lupus erythematosus disease activity index (SLEDAI), systemic lupus international collaboration clinics damage index (SLICC/DI), and APACHE II Score were analyzed. The main outcome variables were morbidity and mortality within 30 days of admission. RESULTS Seventy-three patients were included. Ninety-three percent were female. Most common causes of AAP were: pancreatitis (29%), intestinal ischemia (16%), gallbladder disease (15%), and appendicitis (14%). Most causes of AAP in patients with LES were not related to the disease. APACHE II score > 12 was statistically associated with the diagnosis of intestinal ischemia compared to other causes. No relationship was observed between SLEDAI and outcome. Furthermore, this index did not have impact on diagnosis or decision making. Overall morbidity was 57% and overall mortality 11%. On multivariate analysis, only APACHE II > 12 was associated with mortality (P = 0.0001). CONCLUSION This is one of the largest series of AAP and SLE. Most common causes of AAP were pancreatitis and intestinal ischemia. APACHE II score in patients with intestinal ischemia was higher than those with serositis; further studies are needed to examine whether this score may help to differentiate these etiologies when CT findings are inconclusive. APACHE II score was the most important factor associated with mortality. Furthermore, a prompt diagnosis and an appropriate surgical management are essential in order to improve patient outcome.
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Affiliation(s)
- Omar Vergara-Fernandez
- Department of Surgery, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga No. 15, Col. Seccion XVI Tlalpan, Mexico City, CP, 14000, Mexico.
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Abdominal Manifestations of Systemic Lupus Erythematosus: Spectrum of Imaging Findings. Can Assoc Radiol J 2009; 60:121-32. [DOI: 10.1016/j.carj.2009.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Systemic lupus erythematosus is an immune-mediated syndrome in which the immune response is to non–organ-specific antigens, and virtually every organ in the abdominal cavity may become involved. Only renal involvement forms part of the diagnostic criteria, however, a combination of typically nonspecific findings, including peritoneal surface, enteric, renal, renal tract, pancreatic, adrenal, hepatobiliary, and splenic manifestations, should be looked for in patients with known lupus or other connective tissue disease who are undergoing abdominal imaging and may suggest the diagnosis in patients presenting with an acute abdomen. Our work presents the spectrum of imaging findings of abdominal manifestations of systemic lupus erythematosus.
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47
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Fatal acute pancreatitis complicated by pancreatic pseudocysts in a patient with systemic lupus erythematosus. Rheumatol Int 2009; 30:675-8. [PMID: 19466420 DOI: 10.1007/s00296-009-0964-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 05/03/2009] [Indexed: 10/20/2022]
Abstract
Pancreatitis is a relatively rare but severe manifestation in systemic lupus erythematosus (SLE) patients. We report a case of a 39-year-old woman with previous SLE diagnose treated with prednisone and mycophenolate mofetil who developed an acute pancreatitis complicated by pancreatic pseudocysts within the context of a severe lupus flare. Elevated serum amylase and computerized tomography confirmed the diagnosis and mechanical obstruction or toxic-metabolic etiologies were ruled out. In the present case, we opted for the clinical surveillance of pancreatic pseudocyst and not perform invasive medical procedures to drainage. A steroid therapy was started in order to achieve SLE and pancreatitis remission, however, it was unable to avoid the development of multiorgan failure and patient died a few days after diagnosis was made.
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48
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Myung DS, Kim TJ, Lee SJ, Park SC, Kim JS, Kim JC, Yoon W, Lee SS, Park YW. Lupus-associated pancreatitis complicated by pancreatic pseudocyst and central nervous system vasculitis. Lupus 2009; 18:74-7. [PMID: 19074172 DOI: 10.1177/0961203308093462] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pancreatitis is an uncommon manifestation of systemic lupus erythematosus (SLE), but this can occasionally cause major complications. We report in this article, a case of 33-year-old female patient who developed lupus-associated pancreatitis that was subsequently complicated by pancreatic pseudocyst and central nervous system (CNS) vasculitis. Abdominal computed tomography (CT) showed an oedematous swelling of the pancreas and a pseudocyst measuring 4 x 3 cm2. Brain magnetic resonance imaging (MRI) showed multiple high-signal intensity lesions in both cerebral hemispheres. The pseudocyst did not completely resolve with high-dose steroid therapy, and it was later complicated by infection and rupture. After a surgical drainage for the complicated pseudocyst, her clinical symptoms and signs were markedly improved. This case shows the importance of performing early drainage rather than conservative treatment for a pancreatic pseudocyst in a patient with lupus-associated pancreatitis.
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Affiliation(s)
- D S Myung
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
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49
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Carducci M, Calcaterra R, Mussi A, Franco G, Morrone A. Acute pancreatitis as initial manifestation of systemic lupus erythematosus and subacute cutaneous lupus erythematosus: report of two cases. Lupus 2008; 17:695-7. [DOI: 10.1177/0961203308090429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M Carducci
- San Gallicano Institute IRCCS, Rome, Italy
| | | | - A Mussi
- San Gallicano Institute IRCCS, Rome, Italy
| | - G Franco
- San Gallicano Institute IRCCS, Rome, Italy
| | - A Morrone
- San Gallicano Institute IRCCS, Rome, Italy
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50
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Duval A, Lamare L, Jian R, Pouchot J. Hépatopancréatite inaugurale d’un lupus érythémateux systémique. ACTA ACUST UNITED AC 2008; 32:417-20. [DOI: 10.1016/j.gcb.2008.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 12/02/2007] [Accepted: 01/18/2008] [Indexed: 11/26/2022]
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