Massive Ascites as an Initial Presentation of Systemic Lupus Erythematosus in the Absence of Significant Proteinuria: A Case Report

Systemic lupus erythematosus (SLE) is an autoimmune disease that impacts multiple organ systems, including musculoskeletal, mucocutaneous, hematologic, and renal. Clinical manifestations can range from mild symptoms to severe complications. While gastrointestinal involvement in SLE may occur, abdominal serositis is uncommon, particularly as an initial presentation or without significant proteinuria. This symptom is considered rare and is infrequently reported as an early sign of the disease. We present the case of a 26-year-old female patient who was admitted with recurrent ascites and had no previous history of systemic illnesses. Her symptoms included facial swelling, increased abdominal girth, and shortness of breath. A physical examination revealed periorbital edema and abdominal distension. Initial laboratory tests indicated hypochromic microcytic anemia with no significant proteinuria; a 24-hour urine protein test showed 372.4 mg/24 hours. Elevated inflammatory markers and hypocomplementemia suggested SLE, confirmed by further tests, including positive antinuclear antibodies, anti-double-stranded DNA antibodies, and anti-Smith antibodies. Treatment with intravenous methylprednisolone, hydroxychloroquine, and mycophenolate mofetil resulted in symptom improvement without any further complications. The nonspecific nature and variability of early SLE symptoms can delay diagnosis, underscoring the importance of recognizing atypical presentations. This case highlights the rare occurrence of massive ascites with low-grade proteinuria as an initial sign of SLE, reinforcing the need to include it in the differential diagnosis of unexplained ascites.