Enteritis as initial manifestation of systemic lupus erythematosus in early pregnancy

Abstract

Rational: Lupus enteritis is a rare, severe complication of systemic lupus erythematosus (SLE). We report of a patient who presented with enteritis as manifestation of new-onset SLE during the first trimester of pregnancy. Patients concerns: The 23-year nulliparous patient was admitted to a district hospital with abdominal pain, nausea, vomiting and bloody diarrhea at a gestational age (GA) of 10 weeks. Her symptoms improved with symptomatic treatment and she was discharged a few days later. At 15 weeks' of gestation she was readmitted. Her lab results revealed mild anemia and thrombocytopenia. Ascites, renal failure and proteinuria developed. An infectious cause was suspected, but stool samples and urine cultures were negative. Diagnostic work-up included abdominal ultrasound, gastro-and sigmoidoscopy, magnetic resonance imaging (MRI), and diagnostic laparoscopy. Ultrasound and MRI revealed dilated, fluid-filled small bowel loops, and increased colonic wall diameters. Mucosal edema and petechiae were detected by sigmoidoscopy, and histopathologic examination of the biopsies revealed erosive inflammation. Due to progressive deterioration she was transferred to our center. In addition to ascites, pleural and pericardial effusions had developed. Diagnosis: Diagnosis of SLE was finally established at GA 16 after an autoimmune workup revealed positive antinuclear, anti-Sm, anti-dsDNA and anti-U1RNP antibodies. An interdisciplinary team was set up for her management. She was commenced on corticosteroids; response was only partial and necessitated addition of cyclosporine. The further clinical course was complicated by anemia, chest wall shingles, hypertension, and progressive cervical shortening. Serial ultrasound and Doppler examinations revealed notching of the uterine arteries with raised pulsatility indices and fetal growth restriction. Intervention: At GA 35 abdominal pain reoccurred; a decision for delivery was taken. An apparently healthy fetus was delivered by cesarian section with good Apgar scores and pH (2100g, 9. percentile). The postoperative/postnatal course was unremarkable. Outcomes: New-onset SLE during pregnancy is rare, as is lupus enteritis. To our knowledge, our case is the first report of a combination of both. Lessons: Diagnostic delay occurred a result of symptom overlap and limitations in diagnostic imaging. Interdisciplinary teamwork resulted in successful outcome for both, mother and fetus.