AN UNUSUAL CASE OF LYMPHOCYTIC ENTEROCOLITIS AND VASCULITIS AS THE INITIAL MANIFESTATION OF SLE

PV299 / #287 Case Report Poster Topic: AS23 - SLE-Diagnosis, Manifestations, & Outcomes Introduction Systemic Lupus Erythematosus (SLE) is a complex autoimmune disease with multisystemic involvement, potentially affecting almost every organ. Lymphocytic enterocolitis (LE), or microscopic colitis, is a rare manifestation of SLE. We present an unusual case of a woman with persistent watery diarrhea and LE as the initial presentation of newly diagnosed SLE. Case Presentation With Investigation A 69-year-old woman presented with a 6-month history of watery, non-bloody diarrhea, with mucus, progressively worsening from 1-2 episodes daily to up to 5 episodes. This was associated with a significant weight loss of 17 kg, though she had no abdominal pain, fever, or nocturnal symptoms. Her medical history included hypertension, Raynaud’s phenomenon, and oral ulcers. Physical examination revealed normal bowel sounds without tenderness. Laboratory tests showed leukopenia (WBC = 3,300/ μl 4,500-10,500) with lymphopenia (Lymph=380/ μl 1,200-3,800) elevated ESR =78 mm/h, and mild hypoalbuminemia =3.2 g/dl. (3.5-5.2). Stool cultures and fecal calprotectin tests were unremarkable, as was the initial GI endoscopy. Celiac serology was negative. A repeat colonoscopy due to worsening symptoms revealed multiple shallow, intermittent mucosal ulcers throughout the bowel, while the terminal ileum remained unaffected. Upper GI endoscopy showed mild erosions in the antrum. Bowel histology showed predominant lymphocytic infiltration with mild neutrophilic aggregates, microbleeds, and some vasculitic changes (Picture 1). Fecal calprotectin remained within normal limits. Screening for connective tissue disorders performed due to the presence of mouth ulcers and Raynaud’s phenomenon. This was positive for ANA at 1:1280 (homogeneous pattern), anti-dsDNA at 344 IU/mL (<100), anti-ENA IU/mL at 156 (<20), anti-RNP >100 IU/mL (<20), and anti-Sm at 82 IU/mL (<20), with low complement levels C3 = 35 mg/dl (90-180), C4 = 5 mg/dl (10- 40). An SLE diagnosis was confirmed, and the patient began treatment with methyprednisolone 32mg/daily (with gradual tapering) and Azathioprine (50 mg twice daily), resulting in rapid symptom relief. She remained asymptomatic at the 2-year follow-up. Figure 1: Left image profound lymphocytic infiltrate with neutrophilic aggregations and lymp, Right image, significant lymphocytic infiltrates with evidence of vasculitis (magnified spot) with microbleeds. Literature Review Approximately 40% of SLE patients experience gastrointestinal symptoms, including lupus enteritis, pseudo-obstruction, protein-losing enteropathy, hepatitis, pancreatitis, vasculitis, and mesenteric ischemia.[1] However, lymphocytic enterocolitis is exceedingly rare, with only a few cases documented.[2] Symptoms typically develop insidiously, with fewer, less severe bowel movements than inflammatory bowel disease, and generally respond well to SLE immunosuppressive therapy.[2] Discussion Microscopic enterocolitis can represent an initial manifestation of SLE, and if left untreated, may progress to complications such as vasculitis, as observed in this patient. A thorough medical history is crucial when diagnosing connective tissue diseases, given the broad range of possible clinical presentations. References: [1.] Sultan SM. Rheumatology (Oxford) 1999;38(10):917. [2.] Hegazi MO. Saudi J Gastroenterol 2009;15(4):274-6.