Critical Care: Student/Resident Case Report Poster - Critical Care III |

Systemic Lupus Erythematosus Vasculitis Presenting as Acute Abdomen: A Case Report FREE TO VIEW

Avneet Singh, MS; Masood Komal, MD; Abdulmonam Ali, MD; Fadi Safi, MD
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University of Toledo College of Medicine, Lancaster, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):413A. doi:10.1016/j.chest.2016.08.426
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Systemic lupus erythematosus (SLE) is an autoimmune condition with manifestations that can affect all organs. One manifestation, vasculitis, is characterized by inflammatory infiltrate in vascular cell walls. This can occur in the mesenteric vessels leading to intestinal ischemia and presenting as diffuse abdominal pain1. Here, we present one patient with a history of SLE who presented with signs mimicking acute abdomen and advocate against taking such patients for emergent laporotomy.

CASE PRESENTATION: A 27 year old male with history of mixed connective tissue disorder, systemic lupus erythematosus, Raynaud’s phenomenon, and splenectomy at age 13 presented with pneumococcal sepsis despite adequate vaccination, acute renal failure, and acute respiratory failure status post- intubation. Vitals were a temperature of 104.4 deg F, heart rate 160 and blood pressure of 80/40 mmHg. Workup revealed lactic acidosis, elevated liver transaminases, acute kidney injury, elevated troponin, and elevated creatine kinase. Abdominal CT showed moderate ascites without acute intra-abdominal pathology. Because physical exam demonstrated tenderness, rigidity, and guarding with increasing lactate level, the patient was taken for emergent exploratory laparotomy which only re-demonstrated mild ascites without viscous perforation. His leukocytosis (65,700 cells/mm3) and thrombocytopenia worsened so the patient was started on high dose ceftriaxone and 300 mg daily hydrocortisone for lupus vasculitis. After two days, the patient’s overall condition and abdominal exam improved but his leukocytosis worsened. CT abdomen demonstrated 10-15 liver hypodensities consistent with abscesses so antibiotics were switched to linezolid and meropenem. The patient continued to improve and was transferred out of the ICU 11 days after admission.

DISCUSSION: Lupus mesenteric vasculitis presents as diffuse abdominal pain and can mimic presentations of acute abdomen2. In patients with a history of SLE, there is controversy regarding the decision to employ immediate surgical intervention with concerns for acute abdomen without definitive CT findings which include dilatation, wall thickening, abnormal enhancement, and possible perforation2. Prior to engaging in invasive surgical interventions, reports indicate positive response to high dose prednisolone with addition of cyclophosphamide when the patient does not improve 2.

CONCLUSIONS: Despite prevailing opinion on surgical management of acute abdomen, patients with a history of SLE and negative CT findings should not be taken for exploratory laparotomy before optimizing medical management.

Reference #1: Barille-Fabris L., Hernandez-Cabrera MF., Barragan-Garfias JA. Vasculitis in systemic lupus erythematosus. Current Rheumatology Reports. 2014; 16(9): 440.

Reference #2: Vergara-Fernandez, Omar, Jorge Zeron-Medina, Carlos Mendez-Probst et al. Acute Abdominal Pain in Patients with Systemic Lupus Erythematosus. Journal of Gastrointestinal Surgery 2009; 13: 1351-1357.

DISCLOSURE: The following authors have nothing to disclose: Avneet Singh, Masood Komal, Abdulmonam Ali, Fadi Safi

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