Abdominal pain as the presenting feature of systemic lupus erythematosus (Part 2)

The chest x-ray revealed small bilateral pleural effusions. An ultrasound of the abdomen revealed diffuse small bowel thickening and moderate ascites. A computed tomography of the abdomen (Figure 1) confirmed these findings. Upper gastrointestinal endoscopy was normal and the biopsy of the jejunum (Figure 2) revealed a nonspecific inflammatory infiltrate. Colonoscopy and biopsies of the colon and terminal ileum did not reveal any abnormalities. Echocardiography was unremarkable. A mesenteric angiogram was performed that did not show any evidence of vasculitis on selective celiac, superior mesenteric and bilateral renal selections.

Contrast-enhanced computed tomography of the abdomen

Figure 1) Contrast-enhanced computed tomography of the abdomen demonstrates circumferential bowel wall thickening involving a segment of jejunum (long arrow). A small amount of ascites is also present in the right paracolic gutter (short arrow)

Duodenal biopsy

Figure 2) Duodenal biopsy (Hematoxylin and eosin, original magnification x 252; inset original magnification x 608). The architecture is normal. There is a neutrophilic infiltrate in the superficial epithelium, predominantly in the tips of the villi, and a mild increase in lymphocytes in the deeper glands (inset). There are no infective agents or viral cyto-pathic effects

Further laboratory investigatons revealed that the C3 and C4 were decreased at 0.48 g/L (normal range 0.80 to 1.80 g/L) and 0.05g/L (normal range 0.12 to 0.36 g/L) respectively. The antinuclear antibody titre was positive at 1:160 with a mixed homogenous and speckled pattern. The extractable nuclear antigens (Quanta Lifeā„¢ ELISA; Inova Diagnostics, USA) revealed a weakly positive anti Smith, anti- SCL 70, and anti-SSB. The anti-double stranded DNA was strongly positive at 986 IU/mL (strong positive greater than 801 IU/mL) as was the anti-SSA at 193.8 EU (strong positive greater than 80 EU) A diagnosis of SLE of the small bowel was made. Her oral contraceptives were discontinued upon admission to hospital, but this did not did not change her symptoms. Treatment consisted of azathioprine 50 mg and prednisone 20 mg daily with a prompt resolution of symptoms. Two months after her initial presentation she experienced two episodes of right sided amaurosis fugax. Tests for anticardiolipin antibodies and delayed Russel venom viper test (DRVVT) were negative. Carotid ultrasound, cardiac echocardiogram and magnetic resonance angiography were negative. Acetylsalicylic acid was added to the regimen. Get most advantageous deals offered to you by the pharmacy you are going to appreciate soon after you become its customer: you now can get your glucophage diabetes any time of the day or night with very fast delivery and quality guarantees.

 

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