Systemic Lupus Erythematosus Presenting as Massive Ascites and Pancreatitis

Abstract

MA Mohammed Nur, QQ Contractor, AE Ibrahim, EM Hassan, Systemic Lupus Erythematosus Presenting asMassive Ascites and Pancreatitis. 1996; 16(1): 77-78 Systemic lupus erythematosus (SLE) can present rarely with gastrointestinal tract manifestations such as intestinal obstruction, perforation, protein-losing enteropathy, portal hypertension, Budd-Chiari syndrome, serositis and ascites.1 There are 12 reported cases of SLE with acute pancreatitis in patients who were not on any medications. 2Peritoneal involvement has been found in two-thirds of patients with SLE who undergo necropsy, though it is detected clinically in only 4% to 16%.3 Ascites may present acutely or chronically and massive ascites with SLE is extremely rare. 4Here we report a patient who presented for the first time with massive ascites and pancreatitis due to SLE. Case ReportA 40-year-old Saudi female presented for the first time with a six-week history of anorexia, abdominal pain and distention. She had had polyarthralgia for the previous four years and a single episode of skin rash on the bridge of her nose. The heart was normal and chest examination revealed left pleural effusion. The abdomen was markedly distended with full flanks, everted umbilicus and a fluid thrill which suggested the presence of massive ascites. There was no organomegaly. One week after admission, the patient developed a painful ulcer on the lower lip, measuring 1 cm x 2.5 cm.Laboratory evaluation showed a hemoglobin of 10.5 g/dL, leukocyte count 3.9x10 and ESR 107 mm/lst hour. Serum amylase was 1200 IU (N=0 to 220 IU), liver function tests were unaltered, 24-hour urinary protein was 580 mg and creatinine clearance 75.3 mL/min. Plasma ANF and anti-DNA were positive. HBsAg and anti-HCV were negative. Ascitic fluid amylase was 1890 IU, protein 4.29 g/dL, cell count 50/mm 3 with 97% monocytes; ANF and anti-DNA were positive and culture was sterile. Pleural fluid was also an exudate with positive ANF and anti-DNA. Abdominal ultrasound revealed massive ascites and hypoechoic pancreas while computed tomography (CT) of the abdomen showed ascites and enlarged hypodense pancreas, findings consistent with pancreatitis and ascites.The above investigations suggested a diagnosis of SLE. Prednisolone 1 mg/kg body weight and diuretics were started. As the response was very sluggish over two weeks, azathioprine 2.5 mg/kg was added, with prompt resolution of the ascites. DiscussionAcute pancreatitis with pancreatitis ascites in our patient is suggested by high serum and ascitic fluid amylase as well as findings of abdominal ultrasonography and CT scan. The patient also fulfills the revised American College of Rheumatology criteria for SLE.