Abdominal manifestations in childhood-onset systemic lupus erythematosus

Enteritis: a window to the diagnosis of systemic lupus erythematosus in an adolescent girl: case report

BACKGROUND

Enteritis is one of the rare systemic manifestations in childhood-onset systemic lupus erythematosus and its diagnosis is very challenging. This is a rare case of an adolescent girl with recurrent non-specific gastro-intestinal symptoms which were later diagnosed to be owing to lupus enteritis, the only presenting manifestation of an active flare.

CASE REPORT

A 15-year-old girl was admitted with recurrent episodes of abdominal pain, vomiting and loose stools. She had diffuse abdominal tenderness. Abdominal ultrasonography demonstrated moderate ascites. A contrast-enhanced abdominal computerised tomography scan revealed thickening of the small bowel wall. On colonoscopy, there were rectal erosions, and microscopic examination of the biopsy specimens demonstrated mild inflammation. Non-specific enteritis was diagnosed and she was given antibiotics and supportive care. She was re-admitted 6months later with abdominal pain. An abdominal contrast-enhanced computerised tomography scan revealed thickening of the bowel wall and the target sign and comb sign in the small intestine. The anti-nuclear antibody was positive. Renal biopsy demonstrated grade 2 lupus nephritis. Lupus enteritis was diagnosed and the case satisfied the 2019 EULAR-ACR criteria and SLICC criteria. She was treated with methylprednisolone, cyclophosphamide and hydroxychloroquine. She improved with treatment and has remained asymptomatic during follow-up.

CONCLUSION

This case emphasises the need for healthcare providers to be alert to the possibility of lupus enteritis. It also highlights the importance of close follow-up of cases who have non-specific gastro-intestinal symptoms. Lupus enteritis should be considered in the differential diagnosis of recurrent non-specific gastro-intestinal symptoms in children, especially adolescents, to ensure timely diagnosis and treatment.Abbreviations: ACR American College of Rheumatology; ANA anti-nuclear antibody; CRP: C-reactive protein; CT: computerised tomography; CECT: contrast-enhanced computerised tomography; EULAR: European League Against Rheumatism; GI: gastro-intestinal; LE: lupus enteritis; SLE systemic lupus erythematosis; SLICC: Systemic Lupus International Collaborating Clinics; SLEDAI: SLE disease activity index.

Childhood-Onset Systemic Lupus Erythematosus Presenting With Concomitant Gastrointestinal Manifestation and Antiphospholipid Syndrome

Childhood-onset systemic lupus erythematosus is a rare disease that is more prevalent in Southeast Asian children than in Western children. It is characterised by a peripubertal onset and a female predominance that rises with age. Haematological, renal, and mucocutaneous are among the frequently involved organs upon diagnosis. Some of the typical symptoms include cutaneous vasculitis, malar rash, and fever. Patients frequently had proliferative class IV lupus nephritis, which increases disease activity and kidney damage. We reported a child presented with fever associated with multiple joint pain, skin rashes over the fingers of the right hand, and generalised abdominal pain.

Gastrointestinal endoscopic findings of autoimmune and autoinflammatory diseases in pediatric rheumatology patients

OBJECTIVE

Rheumatic diseases in children are chronic and multisystemic diseases. In this study, it was aimed to evaluate gastrointestinal endoscopic findings in children diagnosed as autoimmune or autoinflammatory rheumatic diseases consulted with pediatric gastroenterology for gastrointestinal complaints.

METHODS

The patients followed up by the Pediatric Rheumatology Department and consulted to the Pediatric Gastroenterology Department due to gastrointestinal complaints were included in the study. File records of the patients were analyzed retrospectively.

RESULTS

A total of 28 patients were included in the study. Twelve of the patients had autoimmune disease (Juvenile idiopathic arthritis [JIA], systemic lupus erythematosus, Sjögren's syndrome, and scleroderma) and the other 16 had autoinflammatory disease (familial Mediterrnean fever, hyper Immunoglobulin D syndrome, undifferantiated systemic autoinflammatory disease, and systemic JIA). Four of the patients with familial Mediterrnean fever also diagnosed as JIA. The mean age of the patients was 11.7±3.5 years. The main gastrointestinal complaints of patients with both autoimmune and autoinflammatory diseases were abdominal pain and diarrhea. Inflammatory bowel disease was found in 33% of those with autoimmune disease and 56% of those with autoinflammatory disease in patients underwent endoscopic evaluation. M694V mutation was present in 62% of the patients with autoinflammatory disease presented with gastrointestinal complaints.

CONCLUSION

Both autoimmune and autoinflammatory rheumatic diseases can cause gastrointestinal complaints and should be referred to a pediatric gastroenterologist for early diagnosis.

Gastrointestinal Involvement in Children with Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder. When it presents before the age of 18 years (childhood-onset systemic lupus erythematosus, cSLE), the disease course tends to be more severe with a higher rate of organ involvement and requires an early diagnosis. Gastrointestinal involvement in cSLE is rare and scarcely reported in the literature. Any organ of the gastrointestinal system may be affected, either as a direct consequence of the disease, as a subsequent complication, or as an adverse drug event. Abdominal pain is the most common GI symptom, it can be diffuse or well localized, and can underline different conditions such as hepatitis, pancreatitis, appendicitis, peritonitis, or enteritis. cSLE may have an alteration of the intestinal barrier with features of protein-losing enteropathy or, in genetically predisposed patients, may develop associated autoimmune disorders such as Coeliac Disease or Autoimmune Hepatitis. The aim of this manuscript is to provide a narrative review of gastrointestinal manifestations in cSLE focused on hepatic, pancreatic, and intestinal involvement. A comprehensive literature search based on the PubMed database was performed.

Systemic Lupus Erythematosus in Disguise: Acute Pancreatitis as Initial Presentation

Macrophage activation syndrome (MAS) can rarely coexist with lupus pancreatitis. We report on a 20-year-old woman with abdominal pain, nausea, and vomiting. Laboratories were notable for pancytopenia, elevated liver enzymes, elevated ferritin, lipase, and triglycerides. Chest and abdominal computerized tomography (CT) scans revealed bilateral axillary lymphadenopathy, patchy lower lobe consolidations, small pleural effusions, ascites, and splenomegaly. Peritoneal fluid cytology showed lymphocytes and histiocytes with hemophagocytic changes. Immunological workup met the criteria for systemic lupus erythematosus (SLE). Pulse-dosed steroids relieved her condition. Given the high mortality rate associated with MAS, early detection of concomitant pancreatitis and MAS in the context of underlying SLE is critical.

Gastrointestinal involvement in systemic lupus erythematosus: A systematic review

Introduction

Gastrointestinal involvement is a common complain observed in 40–60% of systemic lupus erythematosus (SLE) patients. We performed a systematic review of clinically severe and potential life-threatening gastrointestinal manifestations and discuss clinical presentation, pathogenesis and treatment.

Methods

We performed a literature search in English literature using PubMed and Embase from 2000 to December 2020. The following MeSH terms: systemic lupus erythematosus, protein-losing enteropathy, ascites, pancreatitis, vasculitis, intestinal vasculitis, enteritis and diarrhea published in the English literature.

Results

We identified 141 studies (case reports, case series and cohort studies). The most frequent presenting symptoms are acute abdominal pain, nausea, and vomiting. Many of the manifestations were associated with disease activity. Histological features are rarely available, but both vasculitis and thrombosis have been described. There is no treatment guideline. The majority of patients were treated with corticosteroids and the most common immunososupressant were azathioprine, cyclophosphamide and mycophenolate.

Conclusion

Vasculitis and thrombosis may be responsible for severe life-threatening manifestations such as pancreatitis, protein loosing gastroenteritis, acalculous cholecistyitis and enteritis.

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Severe Gastrointestinal manifestations are rare, however potential life threatening.

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Vasculitis and thrombosis are the most frequent pathological mechanism described.

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Cohort studies with analysis of genetic risk factors and the role of autoantibodies could improve diagnosis and prognosis.

Acute acalculous cholecystitis as the initial manifestation of systemic lupus erythematous: A case report

RATIONALE

Acute acalculous cholecystitis (AAC) is an extremely rare manifestation of systemic lupus erythematous (SLE). In previous reports, most of the patients were already diagnosed cases of SLE upon confirmation of AAC.

PATIENT CONCERNS

A 24-year-old female who initially presented with fever and acute right upper quadrant abdominal pain. She had no medical history.

DIAGNOSES

Abdominal ultrasonography and computed tomography (CT) showed gallbladder thickening with pericholecystic edema without gallstones or sludge, demonstrating acalculous cholecystitis. She revealed discoid rash on the both shin. Laboratory tests revealed pancytopenia. The titer of antinuclear antibody (ANA) was 1:1280. Anti-dsDNA antibody, anti-phospholipid antibody, anti-Sm antibody test, and proteinuria in 24 hours were positive. Both C3 and C4 were low. Echocardiography and chest CT showed pericardial effusion and pleural effusion. Using the 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria, the score was 31. We thought AAC of this case that was one of the initial manifestations of SLE.

INTERVENTIONS

The patient was treated with high-dose prednisolone (1 mg/kg) and hydroxychloroquine 400 mg.

OUTCOMES

After 4 days of administration of high-dose corticosteroid therapy, symptoms rapidly improved. After 35 days of the treatment, her symptoms and disease activity of SLE were markedly improved.

LESSONS

Although AAC being the initial manifestation of SLE is very rare, prompt diagnosis and management with corticosteroids precluded surgical intervention. Physicians need to be cognizant of AAC as a disease flare and as a rare initial manifestation of SLE.

Stercoral Colitis in a Patient With Pediatric-Onset Systemic Lupus Erythematosus: Case Analysis and Review of the Literature

Systemic lupus erythematosus (SLE) is an autoantibody-related disease that affects multiple organs. Stercoral colitis (SC) is a rare type of inflammatory colitis with a high mortality rate. Here, we report the first case of pediatric-onset lupus in a case complicated by stercoral colitis. We also conducted a literature review of patients with SC under 30 years old to provide useful clues for rapid diagnosis at a young age. A 28-year-old female with a history of lupus and neuropsychiatric SLE was admitted with severe abdominal pain. She was found to have stercoral colitis during surgery. Two years later, the patient underwent Hartman's operation due to ischemia of the colon. In addition, 10 patients younger than 30 years old with a diagnosis of SC were analyzed based on clinical presentation, physical examination, laboratory exam, imaging and treatment. All cases had a favorable outcome without mortality. Stercoral colitis is a rare but lethal complication, emphasizing the importance of a multidisciplinary approach. Differential diagnosis should include stercoral colitis for patients with SLE developing unexplained sharp abdominal pain.

Lupus enteritis as the sole presenting feature of systemic lupus erythematosus: case report and review of the literature

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune inflammatory disease which can affect any organ, including the gastrointestinal tract. Lupus enteritis is one of the manifestations of gastrointestinal involvement in SLE patients. However, it is exceedingly rare that lupus enteritis is the sole initial presentation of SLE. A 12-year-old Thai girl who had had recurrent abdominal pain for 2 months with no other signs of SLE on initial presentation is described. A single-balloon enteroscopy demonstrated segmental erythema of the proximal and mid-jejunum. Histopathology demonstrated active enteritis and submucosal vasculitis. On the basis of evidence of intestinal vasculitis, autoimmune profiles were performed; the results supported the possibility of SLE. She subsequently developed leucopenia, lymphopenia and an oral ulcer, leading to a robust diagnosis of SLE. Her clinical condition improved dramatically with prednisolone. Even though lupus enteritis is rare, it can be the initial presentation of SLE. In young adolescent girls with recurrent abdominal pain, the possibility of lupus enteritis should be borne in mind.

An Autopsy Case of a 5-Year-Old Child with Acute Pancreatitis Caused by Eosinophilic Granulomatosis with Polyangiitis-like Necrotizing Vasculitis

In children, acute pancreatitis has been reported in IgA vasculitis, Kawasaki disease, systemic lupus erythematosus-associated vasculitis, and juvenile dermatomyositis-associated vasculitis. However, its frequency in these vasculitides has been shown to be low. In other childhood-onset vasculitides, acute pancreatitis is seldom reported. The patient was a 5-year-old Japanese boy who suddenly presented with gastrointestinal (GI) bleeding. Therapy with antiulcer drugs successfully stopped bleeding, but subsequently, high fever, leukocytosis, and hypoxia appeared. He died 12 days after he presented with GI bleeding. An autopsy unexpectedly revealed that necrotizing vasculitis with marked eosinophilic and histiocytic infiltration of the pancreas led to acute pancreatitis, and gastric ulcer with eosinophilic infiltration was shown to be the origin of GI bleeding. In addition, eosinophilic infiltration was found in the small intestine, lungs, and bone marrow. Necrotizing vasculitis with eosinophilic and histiocytic infiltration of the pancreas, eosinophilic infiltration of the airway wall, and eosinophilic gastroenteritis with gastric ulcer were histologically confirmed, suggesting that the present case may be an early stage of eosinophilic granulomatosis with polyangiitis- (EGPA-) like vasculitis. To our knowledge, this might be the first reported case of EGPA-like vasculitis presenting with acute pancreatitis in a child.

Acute pancreatitis and macrophage activation syndrome in pediatric systemic lupus erythematosus: case-based review

Pancreatitis is uncommon in systemic lupus erythematosus (SLE) and is rarely reported in children, possibly being related to macrophage activation syndrome (MAS). The incidence of MAS in children with lupus pancreatitis is unknown, as is their prognosis. In this case-based review, we report a pediatric patient with SLE complicated with pancreatitis and MAS, and performed a literature review. We report an 11-year-old girl with SLE and MAS who developed pancreatitis on the second day of methylprednisolone pulse therapy (500 mg/day). We continued methylprednisolone pulse therapy, and performed three rounds of DNA-immunoadsorption and three rounds of hemoperfusion. A second course of methylprednisolone pulse therapy was initiated 9 days later. The patient received a monthly cyclophosphamide pulse therapy (10 mg/kg/day, 2 consecutive days every month) for 6 months, after which she was treated with mycophenolate mofetil 20 mg/kg/day. The condition of the patient gradually improved, her blood amylase and lipase decreased. She was in a stable condition during 13-month follow-up period. Review of the literature of pediatric patients with SLE and pancreatitis showed that there are 127 cases that have been reported in the past 30 years, 40 cases were excluded in our study because of inadequate information. Of the 87 patients included in our literature review, the mortality rate was 33.33%, and 52.86% of the patients with pancreatitis had MAS at the same time. Pancreatitis is uncommon in SLE, but must be suspected if a patient with SLE develops digestive symptoms. Patients with SLE with pancreatitis have a high incidence of MAS and high mortality rate; however, early recognition and effective treatment can relieve the disease symptoms.

Systemic Lupus Erythematosus-Related Pancreatitis in Children: Severe and Lethal Form

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease of unknown cause, characterized by multisystemic involvement. Its occurrence in children is rare, and acute pancreatitis is exceptional in this matter. Its diagnosis is clinical, biological, and radiological. Its treatment is based on corticosteroid therapy, and its progress is generally lethal. We report two cases of acute pancreatitis in the course of SLE, highlighting its life-threatening severity despite well-conducted treatment. Case 1: 14-year-old patient, admitted to the pediatric ICU for altered state of consciousness. This child, an outpatient since 2009 for chronic arthralgia, was hospitalized five days previously in the pediatric ward for suspicion of severe SLE, before presenting abdominal pain and vomiting. Hyperlipasemia was found, and an abdominal CT scan confirmed the diagnosis of acute pancreatitis. The patient was put under immunosuppressive therapy composed of high-dosage of corticosteroid and cyclophosphamide cures. She died 20 days after her hospitalization by severe lupus flare with multiorgan failure. Case 2: 14-year-old child, admitted to the Pediatric ward for prolonged fever associated with polyarthralgia (nondeforming, immovable, and additive) that had been progressing since 6 months with altered general state; his symptoms got worst 15 days before his hospitalization by having behavioral disorders and epigastralgia with vomiting. Pancreatitis was strongly suspected in the absence of improvement on symptomatic treatment and confirmed by hyperlipasemia 6 times the normal value and a swollen pancreas on the abdominal CT scan. The child was treated with Solumedrol and cyclophosphamide without improvement and then died after one month of hospitalization by a septic shock.

Arterial reconstructions for pediatric splanchnic artery occlusive disease

OBJECTIVE

Pediatric splanchnic arterial occlusive disease is uncommon and a rare cause of clinically relevant intestinal ischemia. This study was undertaken to better define the clinical manifestations and appropriate treatment of celiac artery (CA) and superior mesenteric artery (SMA) occlusive disease in children.

METHODS

Clinical courses of 30 consecutive children undergoing operations for splanchnic arterial occlusive disease at the University of Michigan from 1992 to 2017 were retrospectively analyzed.

RESULTS

Vascular reconstructions were performed for splanchnic arterial disease in 18 boys and 12 girls, 1.5 to 16 years of age (mean, 7.5 ± 4.1 years). Isolated splanchnic arterial disease was uncommon (2 children), being more often associated with abdominal aortic coarctations (19 children) or ostial renal artery stenoses (25 children). Primary splanchnic arterial reconstructions (30) included aortic reimplantation of SMAs (15) or celiacomesenteric arteries (2), aortoceliac and aortomesenteric bypasses (7), reimplantation of the CA as a patch over the stenotic SMA orifice (3), and patch angioplasty of the CA (2) or SMA (1). There was no perioperative mortality. Two groups (I and II) were identified for study. Group I children (14) experienced symptomatic intestinal ischemia, manifested by various combinations of chronic postprandial abdominal discomfort (14), ischemia-related intestinal bleeding (2), or failure to thrive (4). Four children in group I became symptomatic after known CA and SMA occlusive disease was left untreated at the time they underwent earlier interventions for renovascular hypertension. Seven secondary redo interventions were undertaken for recurrent symptoms in six group I children. Only one major periprocedural complication occurred: segmental colon infarction. The assisted patency rate of reconstructed arteries in group I children was 93%, and intestinal ischemic symptoms resolved in every child. Group I follow-up from the most recent splanchnic arterial reconstruction averaged 4.3 years. Group II children (16) without manifestations of intestinal ischemia underwent prophylactic splanchnic arterial reconstructions in concert with combined aortic and renal artery procedures (11), isolated abdominal aortic reconstructions (3), or renal artery reconstructions alone (2). Group II children experienced no major perioperative morbidity and remained asymptomatic postoperatively, and none required secondary splanchnic artery interventions. Group II follow-up averaged 7.4 years.

CONCLUSIONS

Pediatric splanchnic artery occlusive lesions are often associated with developmental aortic and renal artery occlusive disease. Carefully conducted therapeutic and prophylactic reconstructive procedures are appropriate in children having splanchnic arterial occlusive disease.

Successful treatment using corticosteroid combined antibiotic for acute acalculous cholecystitis patients with systemic lupus erythematosus

There is no consensus of treatments for acute acalculous cholecystitis with systemic lupus erythematosus (SLE). The study was aimed to investigate the effect of the corticosteroid for these patients.A series of patients who were diagnosed as acute acalculous cholecystitis with SLE in the period from January 2012 to December 2016 at our hospital were included. They accepted 2 different conservative treatment strategies initially: the treatment using moxifloxacin (the antibiotic group), and the treatment using corticosteroid combined moxifloxacin (the corticosteroid group). Then clinical manifestations, laboratory features, and outcomes were analyzed.The study identified 22 women Han Chinese patients with the SLE history of 2.8 ± 1.4 year. There was no significant difference in SLE history, Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2000), Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (SLICC/ACR), hematologic examination results, and corticosteroid dosage between 2 groups. And there was no significant difference in the symptom of acute cholecystitis, duration of the symptoms, white blood level, and the thickness of gallbladder wall between 2 groups either. However, the SLEDAI-2000 of the corticosteroid group was lower than that of the antibiotic group (7.3 ± 1.4 vs 10.7 ± 3.0, P = .03), so was the SLICC/ACR (0.1 ± 0.3 vs 0.3 ± 0.5, P = .01). Moreover, total 11 of 12 patients were successfully treated in the corticosteroid group, only 1 patient got cholecystectomy because no improvement after conservative treatment. While 4 of 10 patients were successfully treated by moxifloxacin alone, 6 patients had to accept cholecystectomy in the antibiotic group. The rate of successful conservative treatment in the corticosteroid group was higher than that of the antibiotic group (P = .02). All patients were followed up at least 6 months, there was no statistical difference in the rate of recurrence of abdominal pain between 2 groups (P = .37).The corticosteroid plays an important role in the management of the acalculous cholecystitis patient with SLE, and it should be considered as a first line of treatment.

Toxic epidermal necrolysis in a child with lupus-associated pancreatitis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological conditions that are characterized by mucosal erosions, epidermal detachments and erosions. The most common causes of SJS and TEN are drugs; other causes such as systemic lupus erythematosus (SLE), vaccinations and infections have been rarely implicated. We present the case of a 14-year-old female patient with acute pancreatitis as an initial manifestation of systemic lupus erythematosus, complicated by the toxic epidermal necrolysis with a fatal outcome. She initially presented with abdominal pain, fever, vomiting, and intolerance to oral intake and elevated pancreatic enzyme levels. Systemic lupus erythematosus was diagnosed secondary when her condition has been already complicated by the toxic epidermal necrolysis. The administration of corticosteroids and high doses of intravenous immunoglobulin did not lead to positive effects in the treatment of our patient.

Acute acalculous cholecystitis in systemic lupus erythematosus: a rare initial manifestation

Acute acalculous cholecystitis is a very rare gastrointestinal manifestation in systemic lupus erythematosus and becomes rarer as an initial manifestation. There are only two cases reported. The authors report a 20-year-old black woman that presented acute acalculous cholecystitis revealed by abdominal computed tomography. During hospitalization, she was diagnosed systemic lupus erythematosus. Conservative treatment with antibiotics was performed with complete remission of the symptoms. Corticosteroid was started in ambulatory. Cholecystectomy has been the treatment of choice in acute acalculous cholecystitis as a complication of systemic lupus erythematosus. The patient responded well to conservative treatment, and surgery was not required. This case is unique in the way that corticosteroid was started in ambulatory care. We should not forget that the acute acalculous cholecystitis can be the initial presentation of systemic lupus erythematosus although its occurrence is very rare. Conservative treatment should be considered. Abdominal computed tomography was a determinant exam for better assessment of acute acalculous cholecystitis.

Organ involvement other than lupus nephritis in childhood-onset systemic lupus erythematosus

In this review we critically analyze pulmonary, gastrointestinal and cardiac manifestations of childhood-onset systemic lupus erythematosus (cSLE). Clinical manifestations of these organ systems may be the initial manifestation of cSLE; frequently occur with very active cSLE; and are potential life-threatening manifestations often presenting to the emergency department and requiring admission to the intensive care unit. Early recognition and treatment of the pulmonary, gastrointestinal and cardiac manifestations of cSLE will result in improved prognosis and better outcomes.

Differences in disease phenotype and severity in SLE across age groups

Objectives

Significant differences have been reported in disease phenotype and severity of systemic lupus erythematosus (SLE) presenting in different age groups. Most indicate a more severe phenotype in juvenile-onset SLE (JSLE). There have been limited studies in older patients and no large studies looking at SLE across all age groups.

Methods

We assessed the effect of age of onset of SLE on the clinical phenotype by analysing data from two large UK cohorts (the UK JSLE Cohort and the UCLH SLE cohort).

Results

A total of 924 individuals were compared (413 JSLE, 511 adult-onset SLE). A female preponderance was present, but less pronounced at either end of the age spectrum. Arthritis was more common with advancing age (93% vs 72%, p < 0.001), whereas renal disease (44% vs 33%, p = 0.001), alopecia (47% vs 23%, p < 0.001) and aphthous ulcerations (39% vs 26%, p = 0.001) were more common in the young. Neuropsychiatric lupus was less common in mature-onset SLE (p < 0.01). JSLE was associated more commonly with thrombocytopenia (21% vs 15%, p = 0.01), haemolytic anaemia (20% vs 3%, p < 0.001), high anti-dsDNA (71% vs 63%, p = 0.009), Sm (22% vs 16%, p = 0.02) and RNP (36% vs 29%, p < 0.04) auto-antibodies. Leucopenia increased with advancing age (p < 0.001). Mortality has been declining over recent decades. However, death rates were substantially higher than the general population. The standardized mortality ratio was 18.3 in JSLE and 3.1 in adult-onset SLE.

Conclusion

These data from the largest-ever direct comparison of JSLE with adult-onset SLE suggest an aggressive phenotype of disease with a worse outcome in patients with JSLE and emphasizes the importance of careful follow-up in this population.

Pancreatitis Subtypes Survey in 852 Childhood-Onset Systemic Lupus Erythematosus Patients

OBJECTIVE

Pancreatitis is a rare and a life-threatening systemic lupus erythematosus (SLE) manifestation in childhood-onset SLE (cSLE). The objective of this study was to systematically classify pancreatitis in cSLE according to the International Study Group of Pediatric Pancreatitis and determine the overall prevalence, clinical features, laboratory, and first episode outcomes.

METHODS

A multicenter cohort study in 10 pediatric rheumatology centers, including 852 patients with cSLE.

RESULTS

Pancreatitis was diagnosed in 22 of 852 (2.6%) patients with cSLE. It was classified as acute pancreatitis in 20 (91%), acute recurrent pancreatitis in 2 (9%), and none of them had chronic pancreatitis. None of them had gallstones, traumatic pancreatitis, or reported alcohol/tobacco use. The comparison of patients with pancreatitis (first episode) and without this complication revealed a shorter disease duration (1 [0-10] vs 4 [0-23] years, P < 0.0001) and higher median of Systemic Lupus Erythematosus Disease Activity Index 2000 (21 [0-41] vs 2 [0-45], P < 0.0001). The frequencies of fever (P < 0.0001), weight loss (P < 0.0001), serositis (P < 0.0001), nephritis (P < 0.0001), arterial hypertension (P < 0.0001), acute renal failure (P < 0.0001), macrophage activation syndrome (P < 0.0001), and death (P = 0.001) were also higher in patients with pancreatitis. The frequencies of intravenous methylprednisolone use (P < 0.0001) and the median of prednisone dose (55 [15-60] vs 11 [1-90] mg/day, P < 0.0001) were significantly higher in patients with pancreatitis. Of note, the 2 patients with acute recurrent pancreatitis had 2 episodes, with pain-free interval of 1 and 4 years.

CONCLUSIONS

This was the first study characterizing pancreatitis using the International Study Group of Pediatric Pancreatitis standardized definitions in patients with cSLE showing that the predominant form is acute pancreatitis seen in association with glucocorticoid treatment and active severe disease.

Macrophage activation syndrome: A severe and frequent manifestation of acute pancreatitis in 362 childhood-onset compared to 1830 adult-onset systemic lupus erythematosus patients

OBJECTIVE

We previously reported a case series of acute pancreatitis (AP) and macrophage activation syndrome (MAS) in childhood (cSLE) patients; however, there are no data regarding the comparison of AP and MAS in large populations of cSLE and adult SLE (aSLE).

METHODS

A study included 362 cSLE and 1830 aSLE patients. MAS was diagnosed according to preliminary diagnostic guidelines and AP according to the presence of abdominal pain or vomiting associated to an increase of pancreatic enzymes and/or pancreatic radiological abnormalities. Demographic data, clinical features, SLEDAI-2K, SLICC/ACR-DI, and treatment were assessed.

RESULTS

Age in MAS patients was significantly lower compared with those without this complication [15 (8.8-55) vs. 33.5 (10.2-45.7) years, p = 0.007]. The frequencies of fever (94% vs. 37%, p = 0.001), leucopenia (82% vs. 19%, p = 0.0001), thrombocytopenia (65% vs. 19%, p = 0.013), hypertriglyceridemia (87% vs. 42%, p = 0.037), and hyperferritinemia (93% vs. 37%, p = 0.011) were also more frequently observed in AP patients with MAS compared in AP patients without MAS. Fever and hyperferritinemia concomitantly were more frequent in the former group (86% vs. 12%, p = 0.0015). Higher and significant frequency of AP in cSLE compared to aSLE patients [12/362 (3.3%) vs. 20/1830 (1.1%), p = 0.003], with similar AP duration [22 (6-60) vs. 15 (4-90) days, p = 0.534]. MAS (85% vs. 30%, p = 0.003) and death by MAS complication (31% vs. 0%, p = 0.017) were significantly higher in children compared with aSLE.

CONCLUSIONS

This study provides novel data demonstrating that MAS occur in the majority of cSLE with AP with a higher mortality compared to aSLE. In addition, we identified in AP patients, a cluster of MAS clinical and laboratorial parameters more associated with this complication.

Clinical and pathologic characteristics of pancreatic necrosis in critically ill children

BACKGROUND

Pancreatic damage in critically ill patients is associated with the progressive failure of multiple organs, but little is known about its clinical characteristics. At present, no guidelines are available for the diagnosis and management of pancreatic damage. This study was undertaken to analyze the clinical and pathologic characteristics of pancreatic necrosis in critically ill children, and to find some biological markers of pancreatic damage or pancreatic necrosis.

METHODS

We retrospectively reviewed the clinical data, laboratory results, and autopsy findings of 25 children, who were admitted to Hunan Children's Hospital, China from 2003 to 2009, and died of multiple organ failure. The autopsy revealed pancreatic necrosis in 5 children, in whom sectional or gross autopsy was performed.

RESULTS

The 5 children had acute onset and a fever. Two children had abdominal pain and 2 had abdominal bulging, flatulence and gastrointestinal bleeding. Four children had abnormal liver function, characterized by decreased albumin and 3 children had elevated level of C-reactive protein (CRP). B-ultrasonography revealed abnormal acoustic image of the pancreas in all children, and autopsy confirmed pancreatic necrosis, which may be associated with the damage of the adrenal gland, liver, lung, heart, spleen, kidney, intestine, thymus, mediastinal and mesenteric lymph nodes and other organs. Children 1 and 2 died of acute hemorrhagic necrotizing pancreatitis (AHNP); children 3-5 died of multiple organ dysfunction syndrome (MODS) due to pancreatic necrosis.

CONCLUSION

Pancreatic damage or pancreatic necrosis in critically ill children is characterized by acute onset, severity, short course, multiple organ damage or failure. It may be asymptomatic in early stage, and easy to be ignored.

Childhood onset systemic lupus erythematosus: how is it different from adult SLE?

About 20% of systemic lupus erythematosus (SLE) starts in childhood and children have less gender bias in favor of females as compared to adults. Systemic manifestations, nephritis, neuro-psychiatric disease and cytopenias are more common in children at presentation than adults. Since most children develop lupus in their early adolescence, dealing with the diagnosis of an unpredictable lifelong disease during this phase of life is challenging. Physicians must recognise specific medical and social needs of this age group, for optimal long-term outcome. Steroids and immunosuppressive drugs are the cornerstone for treatment in children as with adults with lupus. The outcome has improved considerably with these drugs and 10-year survival is nearly 90%. Due to longer life spans more damage accrues in children as compared to adults. Most of the drugs are associated with significant toxicity and the goal of having a drug which reduces disease activity and damage without hampering normal growth, development and fertility is still an elusive one. The current review focuses on clinical and immunological aspects of childhood SLE and how it differs from adulthood SLE.

Children and adolescents with SLE: not just little adults

Juvenile-onset systemic lupus erythematosus (JSLE) represents 15–20% of all SLE cases. Whilst features of this chronic complex multisystem autoimmune disorder are highly variable, children and adolescents generally present with a more severe illness than adults and accrue greater disease damage over time. JSLE has a less striking female preponderance and differs from the adult form in pattern of major organ manifestations. Corticosteroids are used in almost all children with JSLE along with the majority requiring additional immunosuppressive medications. Making the diagnosis early and optimizing disease control are essential to ensure that normal childhood and adolescent development is not impeded. In this young population, special consideration must be given to the long-term sequelae of the disease and treatment-related toxicity. There is a current lack of paediatric-specific controlled trials and treatment strategies are generally guided by adult data. The enormous psychological and social impact of the disease and its treatments upon the child or young person and their family necessitates a comprehensive, holistic, specialized multidisciplinary approach to managing JSLE.

Granulomatous liver involvement in a child with systemic lupus erythematosus: a case report and review of the literature

Systemic lupus erythematosus (SLE) is uncommon in young children and unusual in infancy. Although a variety of liver pathologies have been reported in SLE, presentation of this disease with granulomatous liver involvement is very rare. In this article, for the first time, we report an infant girl presenting with unexplained hepatosplenomegaly and non-necrotizing granulomatous liver involvement at the age of six months who later developed pancytopenia and proteinuria and was finally diagnosed with SLE at the age of three years. Therefore, we suggest that SLE could be considered as one of the possible differential diagnoses when infants or children present with unexplained granulomatous liver involvement.

Systemic lupus erythematosus-related pancreatitis in children

We report on three patients who developed four episodes of acute pancreatitis while their systemic lupus erythematosus was active and being treated with prednisolone. In all three, gastritis was first considered and treated due to abdominal pain, vomiting, and epigastric tenderness, but their symptoms did not improve. Then pancreatic enzymes were measured, which confirmed pancreatitis. Imaging studies showed an enlarged pancreas in one case, a normal pancreas in two cases, and a focal hypodense nonenhancing parenchyma in one case. Corticosteroids were prescribed for both active SLE and SLE-related pancreatitis. Pulse methylprednisolone was prescribed in one episode, increasing oral prednisolone in one episode, and the same dose of prednisolone continued in the other two episodes. All cases recovered without complications. SLE-related pancreatitis should be considered in SLE patients when the SLE is active and a patient develops abdominal pain and vomiting.

Systemic-lupus-erythematosus-related acute pancreatitis: a cohort from South China

Acute pancreatitis (AP) is a rare but life-threatening complication of SLE. The current study evaluated the clinical characteristics and risk factors for the mortality of patients with SLE-related AP in a cohort of South China. Methods. Inpatient medical records of SLE-related AP were retrospectively reviewed. Results. 27 out of 4053 SLE patients were diagnosed as SLE-related AP, with an overall prevalence of 0.67%, annual incidence of 0.56‰ and mortality of 37.04%. SLE patients with AP presented with higher SLEDAI score (21.70 ± 10.32 versus 16.17 ± 7.51, P = 0.03), more organ systems involvement (5.70 ± 1.56 versus 3.96 ± 1.15, P = 0.001), and higher mortality (37.04% versus 0, P = 0.001), compared to patients without AP. Severe AP (SAP) patients had a significant higher mortality rate compared to mild AP (MAP) (75% versus 21.05%, P = 0.014). 16 SLE-related AP patients received intensive GC treatment, 75% of them exhibited favorable prognosis. Conclusion. SLE-related AP is rare but concomitant with high mortality in South Chinese people, especially in those SAP patients. Activity of SLE, multiple-organ systems involvement may attribute to the severity and mortality of AP. Appropriate glucocorticosteroid (GC) treatment leads to better prognosis in majority of SLE patients with AP.

Systemic lupus erythematosus in children and adolescents

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of disease manifestations that can involve any organ system, and can lead to significant morbidity and even mortality. This article reviews the epidemiology, common clinical features, and complications of the disease, and briefly discusses the available treatment options. In addition, important medical and psychosocial issues relevant to the pediatrician caring for children and adolescents with SLE are discussed.

Pathophysiology, diagnosis, and management of pediatric ascites

The pediatric population has a number of unique considerations related to the diagnosis and treatment of ascites. This review summarizes the physiologic mechanisms for cirrhotic and noncirrhotic ascites and provides a comprehensive list of reported etiologies stratified by the patient's age. Characteristic findings on physical examination, diagnostic imaging, and abdominal paracentesis are also reviewed, with particular attention to those aspects that are unique to children. Medical and surgical treatments of ascites are discussed. Both prompt diagnosis and appropriate management of ascites are required to avoid associated morbidity and mortality.

Acute pancreatitis in children

AIM

To identify clinical, laboratory, and imaging characteristics associated with severe acute pancreatitis in children.

METHODS

This was a retrospective study of children under 18 years of age with acute pancreatitis between September 1993 and August 2008. Severity of pancreatitis was graded according to established criteria. Clinical, laboratory and radiological data for mild and severe pancreatitis were collected for analysis.

RESULTS

There were 180 cases of pancreatitis; 51 (28.3%) met criteria for severe disease. Severe pancreatitis was most commonly associated with systemic disease (22 of 51; 43.1%) and trauma (13 of 51; 25.4%). Patients with severe pancreatitis had significantly higher body weight, higher frequency of dyspnoea and pleural effusion, and lower serum calcium and albumin levels. Ten patients with systemic disease died; four of them had systemic lupus erythematosus (SLE). Computed tomography (CT) was more accurate than ultrasound in evaluation of the severity of pancreatitis.

CONCLUSIONS

Acute pancreatitis in children is associated with significant morbidity and mortality. The severity of paediatric pancreatitis may be influenced by aetiology. CT is recommended for evaluation of severity of pancreatitis.

Acute pancreatitis in pediatric and adult-onset systemic lupus erythematosus: A comparison and review of the literature

This study aimed to compare differences of acute pancreatitis between adult- and pediatric-onset systemic lupus erythematosus (SLE) patients and to clarify the risk factors for mortality. Medical records that carried the dual diagnosis of SLE and acute pancreatitis between 1991 and 2005 were reviewed. Forty-eight episodes of acute pancreatitis were identified in 13 pediatric-onset SLE (pSLE) and 27 adult-onset SLE (aSLE) patients. The prevalence was 1.34% overall, with higher prevalence in pSLE (5.22%) compared with aSLE (0.99%) ( p < 0.001). The SLEDAI score on presentation of acute pancreatitis was higher in pSLE (mean ± SD: 21.77 ± 13.09) than in aSLE patients (13.37 ± 8.32) ( p = 0.05). Eleven patients died during episodes of acute pancreatitis and mortality rate was significantly higher in pSLE than in the aSLE group (53.8% and 14.8%, respectively, p = 0.015). Mortality was associated with concurrent SLE symptoms ( p = 0.049), higher SLEDAI score at presentation of acute pancreatitis ( p = 0.011), severe acute pancreatitis ( p < 0.001), and the presence of complications ( p < 0.001). The multivariate logistic regression analysis showed that severity of acute pancreatitis was the most powerful risk factor for mortality in SLE patients with this disease. In summary, our results indicate that acute pancreatitis occurs more frequently, tends to be more severe, and is associated with higher mortality in pSLE patients when compared with aSLE patient.

Pediatric lupus--are there differences in presentation, genetics, response to therapy, and damage accrual compared with adult lupus?

Some complement deficiencies predispose to systemic lupus erythematosus (SLE) early in life. Currently, there are no known unique physiologic or genetic pathways that can explain the variability in disease phenotypes. Children present with more acute illness and have more frequent renal, hematologic, and central nervous system involvement compared to adults with SLE. Almost all children require corticosteroids during the course of their disease; many are treated with immunosuppressive drugs. Mortality rates remain higher with pediatric SLE. Children and adolescents accrue more damage, especially in the renal, ocular and musculoskeletal organ systems. Conversely, cardiovascular mortality is more prevalent in adults with SLE.

Prognostic impact of atypical presentation in pediatric systemic lupus erythematosus: results from a multicenter study

OBJECTIVES

The aim of the study is to assess the rate of atypical manifestations at onset in pediatric systemic lupus erythematosus (SLE) and to evaluate their effect on disease outcome.

STUDY DESIGN

This is a multicenter retrospective cohort study. A manifestation was considered atypical if it was not included in the American College Rheumatology classification criteria for SLE but was reported in literature as associated with SLE. Unfavorable outcome was considered presence of organ damage in the Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index at the last available evaluation.

RESULTS

One hundred patients were enrolled in the study; 24% presented atypical clinical features at onset. Univariate analysis showed a significant association of worse outcome variables with the presence of atypical manifestations at onset (P = .004), as well as renal involvement (P = .027). A multivariate logistic regression analysis showed that atypical manifestations at onset (P = .018), renal involvement at onset or during follow up (P = .024), and central nervous system disease involvement during follow up (P = .021) were independent predictors of poor prognosis.

CONCLUSIONS

Our data support a relatively high rate of atypical onset in pediatric SLE. Presence of atypical manifestations at presentation and early kidney disease correlate with poor outcome. Similarly, during follow-up, kidney and central nervous system diseases are associated with worse outcome.

The use of tacrolimus for recurrent lupus enteritis: a case report

Introduction

Patients with lupus enteritis sometimes experience recurrence. In such cases, the addition of cyclophosphamide to the treatment regimen is recommended. However, an appropriate treatment has not been established in cases where cyclophosphamide failed to prevent the disease.

Case presentation

An 18-year-old Japanese woman was admitted for a recurrence of lupus enteritis. One year before admission she was treated for lupus enteritis with high-dose corticosteroid together with intravenous cyclophosphamide pulse therapy. Upon admission, she was administered again with high-dose corticosteroid and her abdominal pain rapidly subsided. Tacrolimus was later used as an immunosuppressive agent and a complete remission has been maintained.

Conclusion

Tacrolimus can be a useful agent for recurrent lupus enteritis that is resistant to conventional therapy.

Pancreatitis in systemic lupus erythematosus: frequency and associated factors - a review of the Hopkins Lupus Cohort

OBJECTIVE

Pancreatitis is a rare but potentially life-threatening complication of systemic lupus erythematosus (SLE). Vasculitis of the gastrointestinal tract is the most commonly proposed mechanism. We determined the frequency of SLE-related pancreatitis in the Hopkins Lupus Cohort.

METHODS

A large prospective cohort of 1811 patients with SLE was reviewed and clinical and laboratory measures of SLE patients who developed pancreatitis were compared to patients who did not develop pancreatitis.

RESULTS

Four percent of patients with SLE had pancreatitis due to SLE. The best multivariate model of clinical and laboratory associations included hypertriglyceridemia, psychosis, pleurisy, gastritis, and anemia.

CONCLUSION

Hypertriglyceridemia appears to be a strong associate of pancreatitis in SLE, but antiphospholipid antibodies are not. SLE patients with psychosis and pleurisy are at increased risk for pancreatitis.

Acute pancreatitis as the initial presentation in pediatric systemic lupus erythematosus

It is exceptionally rare for acute pancreatitis to be the presenting manifestation of childhood systemic lupus erythematosus. We report a 14-year-old girl who presented with a history of fever, generalized rash, arthralgia and abdominal pain. Her serum amylase was 1472U/L and lipase 3316 U/L suggestive of acute pancreatitis. Other investigations revealed pancytopenia, low complement, high 24-hour urinary protein and elevated ANA and dsDNA. She was treated with IV methylprednisone, followed by oral steroids.

Abdominal Manifestations of Systemic Lupus Erythematosus: Spectrum of Imaging Findings

Systemic lupus erythematosus is an immune-mediated syndrome in which the immune response is to non–organ-specific antigens, and virtually every organ in the abdominal cavity may become involved. Only renal involvement forms part of the diagnostic criteria, however, a combination of typically nonspecific findings, including peritoneal surface, enteric, renal, renal tract, pancreatic, adrenal, hepatobiliary, and splenic manifestations, should be looked for in patients with known lupus or other connective tissue disease who are undergoing abdominal imaging and may suggest the diagnosis in patients presenting with an acute abdomen. Our work presents the spectrum of imaging findings of abdominal manifestations of systemic lupus erythematosus.