Acute Diarrhea in a Patient With Systemic Lupus Erythematosus

Abstract

INTRODUCTION: Diarrheal disease is one of the leading causes of death across the globe. Acute diarrhea in older adults is mostly due to underlying infectious etiology. Patients with underlying systemic lupus erythematosus (SLE) it is important to consider an acute exacerbation of the disease if presenting with diarrhea and abdominal pain. We are presenting a case of 60-yearold female with remote history of SLE, not on immunosuppressive therapy who presented with rash, dyspnea and acute onset of diarrhea.CASE PRESENTATION: A 60-year-old female with medical history of SLE diagnosed 20 years ago, not on immunosuppressive therapy, and other comorbidities who presented to the emergency department with chief complaint of worsening skin rash, dyspnea and diarrhea. She noted a lacy, macular erythematous rash in both the proximal and distal areas of the arms with a marginated appearance with a central clearing that has been ongoing for over one year; it was not alleviated with topicals. Also, she had multiple loose watery and dyspnea that has been ongoing for the past two weeks. She was treated for an asthma exacerbation seven months ago with oral steroids. Upon presentation, she was tachycardic with mild leukocytosis, lactic acidosis with concern of an underlying abdominal infection. She was empirically started on broad spectrum antibiotics and IV fluids. Significantly elevated CRP and presence of a reticular rash prompted starting IV steroids for concern of vasculitis. Skin biopsy showed leukocytoclastic vasculitis. Serological work-up was significant for positive rheumatoid factor, anti-SSA and ANA. After a few doses of IV steroids, her symptoms improved with dissipation of the rash. With clinical improvement with IV steroids and negative stool cultures, it was suspected that the patient suffered from lupus mesenteric vasculitis. DISCUSSION:The prevalence of vasculitis in a patient with SLE ranges between 11-36%, with cutaneous involvement accounting for 82% of vasculitis and visceral 12.3%. Mesenteric vasculitis is the rarest, and most dangerous complication of SLE that is reported in 0.2 -9.7% of all SLE patients. In this patient's case, she did not have significant knowledge regarding her initial diagnosis of SLE. However, she had been receiving oral steroids for management of asthma or skin rashes intermittently that could have helped control potential SLE flares. For the past seven months, she was not any immunosuppressants that could contribute to worsening rash and diarrhea. A typical presentation of acute diarrhea usually warrants an underlying infectious or inflammatory etiology. This patient's case characteristic rash and remote history of SLE prompt us to further evaluate for an underlying autoimmune culprit due to her symptoms. CONCLUSIONS:It is imperative that we evaluate such patients with an underlying autoimmune disease for any exacerbation as a potential cause of presenting symptoms.