Critical Care

SESSION TITLE: Student/Resident Case Report Poster - Critical Care III

SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

Systemic Lupus Erythematosus Vasculitis Presenting as Acute Abdomen: A Case Report

Avneet Singh MS Masood Komal MD Abdulmonam Ali MD*; and Fadi Safi MD University of Toledo College of
Medicine, Lancaster, OH

INTRODUCTION: Systemic lupus erythematosus (SLE) is an autoimmune condition with manifestations that can affect all
organs. One manifestation, vasculitis, is characterized by inflammatory infiltrate in vascular cell walls. This can occur in the
mesenteric vessels leading to intestinal ischemia and presenting as diffuse abdominal pain1. Here, we present one patient with a
history of SLE who presented with signs mimicking acute abdomen and advocate against taking such patients for emergent
laporotomy.
CASE PRESENTATION: A 27 year old male with history of mixed connective tissue disorder, systemic lupus erythematosus,
Raynaud’s phenomenon, and splenectomy at age 13 presented with pneumococcal sepsis despite adequate vaccination, acute renal
failure, and acute respiratory failure status post- intubation. Vitals were a temperature of 104.4 deg F, heart rate 160 and blood
pressure of 80/40 mmHg. Workup revealed lactic acidosis, elevated liver transaminases, acute kidney injury, elevated troponin,
and elevated creatine kinase. Abdominal CT showed moderate ascites without acute intra-abdominal pathology. Because physical
exam demonstrated tenderness, rigidity, and guarding with increasing lactate level, the patient was taken for emergent exploratory
laparotomy which only re-demonstrated mild ascites without viscous perforation. His leukocytosis (65,700 cells/mm3) and
thrombocytopenia worsened so the patient was started on high dose ceftriaxone and 300 mg daily hydrocortisone for lupus
vasculitis. After two days, the patient’s overall condition and abdominal exam improved but his leukocytosis worsened. CT
abdomen demonstrated 10-15 liver hypodensities consistent with abscesses so antibiotics were switched to linezolid and
meropenem. The patient continued to improve and was transferred out of the ICU 11 days after admission.
DISCUSSION: Lupus mesenteric vasculitis presents as diffuse abdominal pain and can mimic presentations of acute abdomen2.
In patients with a history of SLE, there is controversy regarding the decision to employ immediate surgical intervention with
concerns for acute abdomen without definitive CT findings which include dilatation, wall thickening, abnormal enhancement, and
possible perforation2. Prior to engaging in invasive surgical interventions, reports indicate positive response to high dose
prednisolone with addition of cyclophosphamide when the patient does not improve 2.

CRITICAL CARE
CONCLUSIONS: Despite prevailing opinion on surgical management of acute abdomen, patients with a history of SLE and
negative CT findings should not be taken for exploratory laparotomy before optimizing medical management.
Reference #1: Barille-Fabris L., Hernandez-Cabrera MF., Barragan-Garfias JA. Vasculitis in systemic lupus erythematosus.
Current Rheumatology Reports. 2014; 16(9): 440.
Reference #2: Vergara-Fernandez, Omar, Jorge Zeron-Medina, Carlos Mendez-Probst et al. Acute Abdominal Pain in Patients
with Systemic Lupus Erythematosus. Journal of Gastrointestinal Surgery 2009; 13: 1351-1357.
DISCLOSURE: The following authors have nothing to disclose: Avneet Singh, Masood Komal, Abdulmonam Ali, Fadi Safi
No Product/Research Disclosure Information
DOI: http://dx.doi.org/10.1016/j.chest.2016.08.426
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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