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Vulasala SS, Singareddy A, Dasari SM, Wallack M, Gopireddy D. Ruptured Mycotic Aneurysm of the Superior Mesenteric Artery: A Case Report. Cureus 2024; 16:e54004. [PMID: 38476804 PMCID: PMC10928462 DOI: 10.7759/cureus.54004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/11/2024] [Indexed: 03/14/2024] Open
Abstract
An infected (mycotic) aneurysm of the visceral arteries is an uncommon entity, which may arise from a secondary infection of a preexisting aneurysm or be due to degeneration from a primary infection. Mycotic aneurysms require prompt recognition and definitive treatment; otherwise, there can be devastating morbidity and mortality. We present the case of a 51-year-old female with HIV and Crohn's disease who presented with subacute abdominal pain, nausea, and vomiting and was found to have an ultimately fatal mycotic aneurysm of the superior mesenteric artery. In addition, we discuss the characteristic imaging features of mycotic aneurysms on computed tomography and magnetic resonance imaging.
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Affiliation(s)
- Sai Swarupa Vulasala
- Radiology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Anastasia Singareddy
- Skin Biology and Dermatological Sciences, University of Miami Miller School of Medicine, Miami, USA
| | | | - Max Wallack
- Radiology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Dheeraj Gopireddy
- Radiology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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Muñoz-Urbano M, Sangle S, D'Cruz DP. Lupus enteritis: a narrative review. Rheumatology (Oxford) 2024:kead689. [PMID: 38216993 DOI: 10.1093/rheumatology/kead689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/20/2023] [Accepted: 12/02/2023] [Indexed: 01/14/2024] Open
Abstract
Lupus enteritis (LE) is a rare manifestation of systemic lupus erythematosus. The pathophysiology of LE has not been fully elucidated, although inflammatory and thrombotic processes are likely important factors. The underlying pathophysiological mechanisms may depend on which portion of the intestine is affected. Over half of the patients with LE also present with renal or haematological complications. The diagnosis of LE is based on clinical, histopathological, and imaging findings; abdominal computed tomography (CT) is the gold standard in diagnosis. Abdominal CT can also identify factors that predict complications and could potentially guide pharmacological and nutritional management. Timely identification and prompt treatment initiation are paramount to avoid life and organ threatening complications. Glucocorticoids are often the first line treatment. Additional therapy including immunosuppressive therapy is utilised on a case-by-case basis as there are no clinical trials to define the optimal therapeutic approach. Surgical intervention may be needed especially if there is bowel perforation or peritonitis. In general the prognosis of LE is good.
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Affiliation(s)
- Marcela Muñoz-Urbano
- Rheumatology Department, Clínica Imbanaco, Grupo Quirónsalud, Cali, Colombia
- Louise Coote Lupus Unit, Guy's Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Shirish Sangle
- Rheumatology Department, Clínica Imbanaco, Grupo Quirónsalud, Cali, Colombia
- Louise Coote Lupus Unit, Guy's Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - David P D'Cruz
- Rheumatology Department, Clínica Imbanaco, Grupo Quirónsalud, Cali, Colombia
- Louise Coote Lupus Unit, Guy's Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
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Muñoz-Urbano M, Sanchez-Bautista J, Ramírez A, Santamaría-Alza Y, Quintero-González DC, Vanegas-García AL, Vásquez G, González LA. Lupus enteritis: A 10-year experience in a single Latin American center. Lupus 2023:9612033231175782. [PMID: 37184366 DOI: 10.1177/09612033231175782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE The objective is to compare the clinical and laboratory characteristics of systemic lupus erythematosus (SLE) patients with and without lupus enteritis (LE) and to identify the factors associated with the occurrence of LE. METHODS We performed a retrospective, case-control study in hospitalized patients with SLE who were admitted to our tertiary hospital between January 2012 and December 2021. Sixteen LE patients (cases) were matched (1:3 ratio) for sex and birth year with 48 non-LE patients (controls). Univariable and multivariable logistic regression analyses were used to identify the variables associated with LE. RESULTS Of 2,479 SLE patients who were admitted to our hospital as inpatients, 16 (0.65%) were diagnosed as having LE. All patients, cases and controls, were of Mestizo ethnicity. SLE was diagnosed simultaneously with the first episode of LE in 10 (62.5%) patients. The median time from SLE diagnosis to the first episode of LE was 7 (IQR 0-78) months. LE patients had a shorter median disease duration [7 (0-78) vs 34 (9.5-79) months], and a significantly longer hospital stay (28.3 ± 15.8 vs 6.5 ± 7.9 days, p < 0.001) than non-LE patients. Most LE patients (93.8%) had concomitant lupus nephritis. LE patients had higher SLEDAI-2K scores than those without LE (20.5 ± 9.4 vs 9.8 ± 10.4, p < 0.001). By multivariable analysis, a higher SLEDAI-2K score (OR 1.10, 95% CI 1.02-1.18; p = 0.015) was independently associated with LE occurrence after adjusting for cutaneous involvement, lymphocyte count, serum creatinine, and serum complement C4. Recurrence was observed in two patients (12.5%), both with a bowel wall thickening > 8 mm. The two patients with large intestine-dominant LE developed intestinal pseudo-obstruction. No patient had life-threatening complications (intestinal hemorrhage, infarction, or perforation), and there were no deaths induced directly by LE itself. CONCLUSION In patients of Mestizo ethnicity, LE occurs during the early course of SLE, frequently is one of the presenting manifestations of SLE, and in most cases, it presents with concomitant lupus nephritis. Higher levels of disease activity at diagnosis were independently associated with LE occurrence and when recurrences occur, they do so in the context of severe wall thickness.
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Affiliation(s)
- Marcela Muñoz-Urbano
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
| | - Julián Sanchez-Bautista
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
| | - Andrés Ramírez
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
| | - Yeison Santamaría-Alza
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
| | - Diana C Quintero-González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
| | - Adriana-Lucía Vanegas-García
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
| | - Gloria Vásquez
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
| | - Luis A González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital San Vicente Fundación, Medellín, Colombia
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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) 2023; 10:children10020309. [PMID: 36832440 PMCID: PMC9955206 DOI: 10.3390/children10020309] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Potera J, Palomera Tejeda E, Arora S, Manadan AM. Lupus Enteritis: An Uncommon Presentation of Lupus Flare. Cureus 2021; 13:e18030. [PMID: 34671520 PMCID: PMC8520498 DOI: 10.7759/cureus.18030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/23/2022] Open
Abstract
Gastrointestinal (GI) symptoms are common in systemic lupus erythematosus (SLE) but are usually attributable to medication side effects, infections, or other underlying conditions. In rare cases, they are caused by the autoimmune process itself. In this report, we present two cases of lupus enteritis as the sole manifestation of lupus flare. We also provide a comprehensive review of available literature on this topic with a specific focus on clinical symptoms, complications, laboratory findings, histology, imaging findings, and therapies. Lupus enteritis is an uncommon manifestation of SLE. CT scan of the abdomen is the diagnostic modality of choice. The three major CT findings are target sign, comb sign, and increased mesenteric fat attenuation. Ascites is also commonly present. Corticosteroids and second-line immunosuppressants have been successfully employed in the treatment of lupus enteritis. Our cases highlight this unusual manifestation as the only symptom of active SLE. A high index of suspicion should be maintained when evaluating SLE patients presenting with GI symptoms to prevent diagnosis and treatment delays that could lead to serious complications such as bowel necrosis, perforation, and even death.
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Affiliation(s)
- Joanna Potera
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | | | - Shilpa Arora
- Rheumatology, Rush University Medical Center, Chicago, USA
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Abstract
Systemic lupus erythematosus (SLE) is a complex multisystemic autoimmune disease. Lupus enteritis (LE), one of the less commonly described manifestations of childhood SLE, presents with relatively nonspecific clinical and laboratory features. In addition, recurrent episodes of LE occurring in temporal proximity are rare in children. Presence of disease activity at other sites (which may not be seen universally) supports the diagnosis of LE in an appropriate setting. Because of its potential role to cause ischemic complications, early recognition and prompt treatment are necessary for a good outcome. Herein, we describe a child with recurrent LE with an interval of about 3 months between the first and the second episode. The first episode correlated with systemic disease activity and bowel thickening was noted on abdominal ultrasonography. This episode was successfully managed with intravenous methylprednisolone pulse therapy. Conversely, the second episode was not associated with significant clinical and laboratory evidence of disease activity at other sites and the initial abdominal ultrasonography was non-contributory. Diagnostic and therapeutic delays, hence, led to the development of fatal complications. We highlight that a high index of suspicion of LE and a timely aggressive treatment is imperative for optimal outcomes even in rare pediatric cases of recurrent LE that may have normal imaging findings initially and may not be associated with systemic lupus erythematosus disease activity index (SLEDAI).
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Affiliation(s)
- Pratap Kumar Patra
- Department of Pediatrics, Allergy Immunology Unit, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dharmagat Bhattarai
- Department of Pediatrics, Allergy Immunology Unit, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aaqib Zaffar Banday
- Department of Pediatrics, Allergy Immunology Unit, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anju Gupta
- Department of Pediatrics, Allergy Immunology Unit, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nitin James Peters
- Department of Pediatric Surgery, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Akshay Saxena
- Department of Radiodiagnosis, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Maruyama A, Nagashima T, Iwamoto M, Minota S. Clinical characteristics of lupus enteritis in Japanese patients: the large intestine-dominant type has features of intestinal pseudo-obstruction. Lupus 2018; 27:1661-1669. [PMID: 30028259 DOI: 10.1177/0961203318785770] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was performed to investigate the clinical characteristics of lupus enteritis in Japanese patients with systemic lupus erythematosus (SLE). A total of 481 patients with SLE admitted to our hospital between 2001 and 2015 were retrospectively reviewed. Diagnosis of lupus enteritis was based on the following three criteria: (1) abdominal symptoms, (2) diffuse long-segment bowel thickening and (3) a requirement for glucocorticoid therapy. Lupus enteritis was identified in 17 patients (3.5%) and there were two distinct types: small intestine-dominant and large intestine-dominant. Significant differences between the two types were noted with respect to the age, frequency of biopsy-proven lupus nephritis, frequency of rectal involvement, maximum bowel wall thickness, and requirement for steroid pulse therapy. Among patients with large intestine-dominant lupus enteritis, 60% had extra-intestinal symptoms (hydroureter, bladder wall thickening, and bile duct dilatation) that are known complications of intestinal pseudo-obstruction. Two patients with large intestine-dominant lupus enteritis developed intestinal pseudo-obstruction either before or after diagnosis of lupus enteritis. Five patients (29%) developed recurrence during a median observation period of 7.2 years (1.4-14.4 years). In conclusion, large intestine-dominant lupus enteritis resembles intestinal pseudo-obstruction and these two diseases may have a common pathogenesis.
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Affiliation(s)
- A Maruyama
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - T Nagashima
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - M Iwamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - S Minota
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
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Kim YG, Kim SR, Hwang SH, Jung JY, Kim HA, Suh CH. Mesenteric vasculitis after G-CSF administration in a severe neutropenic patient with systemic lupus erythematosus. Lupus 2016; 25:1381-4. [PMID: 27009623 DOI: 10.1177/0961203316640914] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/27/2016] [Indexed: 11/15/2022]
Abstract
Granulocyte colony-stimulating factor (G-CSF) is commonly used with neutropenic patients to accelerate recovery. G-CSF is a hematopoietic cytokine that regulates the proliferation and differentiation of neutrophil precursors, and is known as a safe and effective treatment for chemotherapy-induced neutropenia. However, we encountered a case in which a patient with systemic lupus erythematosus (SLE) developed mesenteric vasculitis after G-CSF administration. The patient was a 36-year-old female admitted with fever, arthralgia, and generalized erythematous rash. Despite symptomatic improvement with a high-dose steroid, severe neutropenia persisted for three weeks, precipitating a decision to use G-CSF to enhance recovery. Mesenteric vasculitis developed 15 hours after administration of G-CSF injection. Because the response of immune cells such as neutrophils and T cells is uncontrolled and dysfunctional in patients with lupus, G-CSF therapy should be used with caution.
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Affiliation(s)
- Y-G Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - S-R Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - S-H Hwang
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - J-Y Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - H-A Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - C-H Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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