UNUSUAL PRESENTATION OF LUPUS ENTERITIS WITH COLORECTAL INVOLVEMENT: A RARE CASE REPORT IN BANGLADESH

PV292 / #338 Case Report Poster Topic: AS17 - Miscellaneous Introduction Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease of young that can affect any organs of the body. About 40% of SLE patients have gastrointestinal issues during their lifetime. Lupus enteritis (LE) may be a serious complication carries a high risk of mortality. It usually involves the mesenteric arteries causing ischemic changes of the small bowels but rarely involves large bowels, especially to the colon and rectum. Case Presentation With Investigation Here we presented a 17-year-old girl who is a known case of SLE, diagnosed with colorectal LE after initial presentation with intermittent abdominal pain, vomiting and occasional diarrhea for 2 months at Rheumatology department of BIRDEM General Hospital, Dhaka, Bangladesh on 29 th September 2024. During her hospital course, she had mid abdominal pain for 3 days, which was sudden, severe, colicky, had no aggravating or relieving factors, no-radiation, associated with vomiting & bloody diarrhea. She didn’t give any history of hemoptysis, weight loss or fever. One year back, she was diagnosed as SLE on the basis of polyarthritis, oral ulcer, photosensitivity, excessive hair loss and skin rash with positive ANA and Anti dsDNA. She was on hydroxychloroquine, low-dose prednisolone and methotrexate. But she had been irregular in taking medications, which may have contributed to the onset of LE and led to her current hospital admission. According to the 2019 European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) Classification criteria for SLE her score was 22. Additionally, abdominal computed tomography (CT) and CT angiogram of abdominal aorta with other relevant investigations revealed distended bowel loops, significant wall thickening and luminal narrowing with hallow sign at intestinal wall especially proximal rectum including rectosigmoid junction. Increased echogenicity surrounding the bowel loops with engorged mesenteric vessels and mild to moderate ascites was found. All these findings were consistent with colorectal LE. Laboratory tests also showed lower levels of complement C3 and C4, with a very high titer (1:800) of anti dsDNA. Overall, it was clear that this case involved colorectum, representing a rare manifestation of lupus gut. The patient received treatment with hydroxychloroquine, intravenous pulse methylprednisolone followed by high dose oral prednisolone and pulse cyclophosphamide along with nutritional support. After 1 week of treatment her condition improved significantly. Literature Review SLE can affect the entire GI tract, from the oral mucosa to the rectum. The percent of patients of GI tract related symptom is up to 40%-50% but the development of LE is present in only about 0.2% to 5.8% of patients. LE involving the jejunum and ileum (83% and 84%, respectively) are relatively common, but involvement of the colon (19%) and rectum (4%) with or without involvement of the small intestine is extremely rare. Discussion Lupus enteritis generally affects the small intestine, but in rare cases, it can involve the colon presenting an unusual and diagnostically challenging manifestation. Colorectal involvement may lead to symptoms like abdominal pain and bloody stools which can mimic inflammatory bowel disease or infectious colitis. Recognizing atypical presentation is crucial, as early treatment with corticosteroids and immunosuppressants can prevent complications including ischemia and perforation, associated with colonic involvement.