Protein-losing enteropathy as the first presentation of systemic lupus erythematosus: A case report from Sudan

Key Clinical Message

In low- and middle-income countries, protein-losing enteropathy is a diagnosis of exclusion. SLE should be on the list of differential diagnoses of protein-losing enteropathy, especially if the patient had a long history of GI symptoms and ascites.

Abstract

Protein-losing enteropathy can rarely be the initial presentation of systemic lupus erythematosus (SLE). Protein-losing enteropathy is a diagnosis of exclusion in low- and middle-income countries. Protein-losing enteropathy in SLE should be in the list of differential diagnosis of unexplained ascites, especially if patient had long history of gastrointestinal symptoms. We present a case of 33 years old male with long standing gastrointestinal symptoms and diarrhea attributed previously to irritable bowel syndrome. Presented with progressive abdominal distension, and diagnosed with ascites. Workup for him showed leucopenia, thrombocytopenia, hypoalbumenemia, elevated inflammatory markers (ESR 30, CRP 6.6), high cholesterol level (306 mg/dL), normal renal profile and normal urine analysis. Ascitic tab pale yellow with SAAG 0.9 and positive for adenosine deaminase (66 u/L) sugesstive for tuberculous peritonitis although quantitative PCR and geneXpert for MBT was negative. Antituberculous treatment was started and his condition deteriorated, immediately antituberculous was withdrawal. Further tests revealed positive serology for ANA (1:320 speckled pattern) with positive anti-RNP/Sm, positive anti-Sm antibodies. Complements level were normal. He started immunosuppressive therapy (prednisolone 10 mg/day, hydroxychloroquine 400 mg/day, azathioprine 100 mg/day). In addition, his condition is improved Diagnosis was made as SLE with Protein-losing enteropathy based on hypoalbumenemia (with exclusion of renal loss of protein), ascites, hypercholesrtolemia and exclusions of other mimics as explained later. As well as positive response to immunosuppressive medications. Our patient diagnosed clinically as SLE with protein-losing enteropathy. Protein-losing enteropathy in SLE is challenging in diagnosis because of its rarity as well as limitations in its diagnostic tests.

The co-infection of Buruli ulcer and cutaneous leishmaniasis in Sudanese patient: An association by choice or by chance?

Buruli ulcer and cutaneous leishmaniasis both have the similar cutaneous clinical presentation. Therefore, relying on clinical diagnosis can be challenging. We present a case of 45 years old woman diagnosed with cutaneous leishmaniasis, confirmed by skin biopsy. She received different modalities of anti-leishmanial treatment (fluconazole 450mg daily for 4 weeks, sodium stibogluconate (SSG) followed by thermal therapy, SSG/IV 20mg/kg for 30 days combined with paromomycin 15mg/kg IM for 17 days). These treatments were associated with partial improvement of the ulcer and failure of healing. A second biopsy demonstrated the presence of Mycobacterium ulcerans and hence the diagnosis of Buruli ulcer as a cause of the delayed healing of the ulcer. M. ulcerans releases a toxin known as mycolactone, which decreases immune system function and results in tissue death. M. ulcerans, is regarded as the third most prevalent Mycobacterium after M. tuberculosis and M. leprae. Treatment with streptomycin intramuscular injections 1g daily and rifampicin 600mg daily for 8 weeks was associated with complete healing of the ulcer. To our knowledge, this is the first report that describes the co-infection of Buruli ulcer and cutaneous leishmaniasis in Sudan.