1
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Huang H, Li P, Zhang D, Zhang MX, Yu K. Acute flare of systemic lupus erythematosus with extensive gastrointestinal involvement: A case report and review of literature. World J Gastrointest Surg 2023; 15:2074-2082. [PMID: 37901723 PMCID: PMC10600777 DOI: 10.4240/wjgs.v15.i9.2074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/09/2023] [Accepted: 07/28/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Lupus mesenteric vasculitis (LMV) is a serious condition that may occur as an acute manifestation of gastrointestinal (GI) involvement and is not easily diagnosed by physicians. Delayed diagnosis and treatment of LMV may lead to rapid disease progression and can be life threatening. CASE SUMMARY A previously healthy 27-year-old woman presented with abdominal pain following a history of fatigue and consumption of cold water. Laboratory investigations, physical examinations, and enhanced abdominal computed tomography (CT) suggested systemic lupus erythematosus complicated by LMV. She received treatments, such as GI decompression, somatostatin, glucocorticoids, and immunosuppressants, and was evaluated using color ultrasonography. Twenty days later, the patient reported no stomach discomfort and was able to consume semi-liquid food. Laboratory investigations showed that inflammatory factors decreased to normal levels and complement levels increased slightly. One year after discharged, she recovered with methylprednisolone being tapered to 4 mg per day, mycophenolate mofetil to 0.75 g bid, and hydroxychloroquine to 0.2 g bid; however, only C3 complement level was slightly below the normal level. CONCLUSION Early diagnosis of LMV is essential for successful treatment; this depends on a combination of clinical manifestations, laboratory investigations, and imaging findings. Enhanced CT is preferred, but ultrasonography can be used for prompt screening and follow-up.
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Affiliation(s)
- Hua Huang
- Department of Rheumatology and Immunology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Ping Li
- Department of Rheumatology and Immunology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Dan Zhang
- Department of Nutrition, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Ming-Xuan Zhang
- Department of Rheumatology and Immunology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Kai Yu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
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2
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Ng DM, Sek K, Nossent J. Protein-losing enteropathy as a rare manifestation of systemic lupus erythematosus. BMJ Case Rep 2023; 16:e256680. [PMID: 37640422 PMCID: PMC10462934 DOI: 10.1136/bcr-2023-256680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- David Michael Ng
- Rheumatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Kenny Sek
- Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Johannes Nossent
- Rheumatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Rheumatology Unit, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
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3
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Abdalla E, Mohymeed N, Nail AMA, Tonga RA, Alfatih M, Abdalfdeel Almahie Shaban M, Eltoum H. Protein-losing enteropathy as the first presentation of systemic lupus erythematosus: A case report from Sudan. Clin Case Rep 2023; 11:e7314. [PMID: 37180328 PMCID: PMC10172448 DOI: 10.1002/ccr3.7314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/03/2023] [Accepted: 04/21/2023] [Indexed: 05/16/2023] Open
Abstract
Key Clinical Message In low- and middle-income countries, protein-losing enteropathy is a diagnosis of exclusion. SLE should be on the list of differential diagnoses of protein-losing enteropathy, especially if the patient had a long history of GI symptoms and ascites. Abstract Protein-losing enteropathy can rarely be the initial presentation of systemic lupus erythematosus (SLE). Protein-losing enteropathy is a diagnosis of exclusion in low- and middle-income countries. Protein-losing enteropathy in SLE should be in the list of differential diagnosis of unexplained ascites, especially if patient had long history of gastrointestinal symptoms. We present a case of 33 years old male with long standing gastrointestinal symptoms and diarrhea attributed previously to irritable bowel syndrome. Presented with progressive abdominal distension, and diagnosed with ascites. Workup for him showed leucopenia, thrombocytopenia, hypoalbumenemia, elevated inflammatory markers (ESR 30, CRP 6.6), high cholesterol level (306 mg/dL), normal renal profile and normal urine analysis. Ascitic tab pale yellow with SAAG 0.9 and positive for adenosine deaminase (66 u/L) sugesstive for tuberculous peritonitis although quantitative PCR and geneXpert for MBT was negative. Antituberculous treatment was started and his condition deteriorated, immediately antituberculous was withdrawal. Further tests revealed positive serology for ANA (1:320 speckled pattern) with positive anti-RNP/Sm, positive anti-Sm antibodies. Complements level were normal. He started immunosuppressive therapy (prednisolone 10 mg/day, hydroxychloroquine 400 mg/day, azathioprine 100 mg/day). In addition, his condition is improved Diagnosis was made as SLE with Protein-losing enteropathy based on hypoalbumenemia (with exclusion of renal loss of protein), ascites, hypercholesrtolemia and exclusions of other mimics as explained later. As well as positive response to immunosuppressive medications. Our patient diagnosed clinically as SLE with protein-losing enteropathy. Protein-losing enteropathy in SLE is challenging in diagnosis because of its rarity as well as limitations in its diagnostic tests.
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Affiliation(s)
- Elham Abdalla
- Department of Internal MedicineBahri UniversityKhartoumSudan
| | - Noon Mohymeed
- Department of Internal MedicineOmdurman Islamic UniversityKhartoumSudan
| | | | - Rayan Ali Tonga
- Department of Internal MedicineSudan Medical Specialization BoardKhartoumSudan
| | | | | | - Hassan Eltoum
- Department of Internal MedicineOmdurman Islamic UniversityKhartoumSudan
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4
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Muacevic A, Adler JR, Lynce A, Correia MJ, Ribeiro AM. Post-partum Fever of Unknown Origin: An Inaugural Flare of Severe Lupus With Multisystemic Involvement and Hemophagocytic Syndrome. Cureus 2023; 15:e33348. [PMID: 36751216 PMCID: PMC9896851 DOI: 10.7759/cureus.33348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 01/06/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect almost every organ. Lupus protein-losing enteropathy (PLE) is one of the rarest manifestations of gastrointestinal involvement. Lupus flare as initial presentation is rare and the disease can act as a trigger to other pathologic immune syndromes like Hemophagocytic Lymphohistiocytosis (HLH), although this association is rare. We report the case of a previously healthy African 39-year-old female patient, with a recent history of cesarean section. Admitted to the Emergency Department (ED) with diffuse abdominal pain and fever, having completed a cycle of antibiotic therapy for initially suspected endometritis. The clinical picture progressed with sustained high fever, new-onset lymphadenopathies, systemic rash, acute pulmonary edema and seizures. Laboratory findings included hyperferritinemia, hypertriglyceridemia, proteinuria and hypoalbuminemia. The auto-immune panel was positive for antinuclear antibodies (ANA), anti-dsDNA, anti-SSA and anti-SSB, anti-PL7, anti-RNP, anti-U1-SnRNP, and anti-Pm-Scl75. She also presented hypocomplementemia. An inaugural flare of SLE with multisystemic involvement and concomitant secondary Hemophagocytic Syndrome was considered and therapy with methylprednisolone pulses, Anakinra and Cyclophosphamide was started. By the end of the first cycle of cyclophosphamide, the patient presented clinical worsening with abdominal pain recrudescence and profuse diarrhea. After the exclusion of an infectious process, a Lupus PLE was assumed and Cyclophosphamide protocol was resumed, with sustained clinical improvement after the induction protocol. Despite initially suspected gynecological infection, the clinical progression with multisystemic involvement together with the auto-immune panel made the diagnosis of SLE possible, with other laboratory findings raising the suspicion of HLH. This case represents a rare report of severe SLE with multiple organ involvement accompanied by HLH. Gastrointestinal involvement with PLE added rarity and morbidity to the clinical picture. The case reinforces the idea that when organ dysfunction is due to a severe autoimmune response, supportive treatment can be lifesaving until immunosuppressive drugs reach their full effect.
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5
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Tanaka M, Kawaratani H, Noguchi R, Koizumi A, Shibamoto A, Kaji K, Shimozato N, Kojima K, Nishimura Y, Yoshiji H. Protein-losing gastroenteropathy complicated with asymptomatic primary biliary cholangitis, refractory to immunosuppressant, and improved by Helicobacter pylori eradication: a case report. BMC Gastroenterol 2022; 22:101. [PMID: 35255813 PMCID: PMC8900399 DOI: 10.1186/s12876-022-02170-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 02/18/2022] [Indexed: 12/01/2022] Open
Abstract
Background Protein-losing gastroenteropathy (PLGE) is a syndrome with a chief complaint of hypoalbuminemia, which occurs due to plasma protein leakage in the gastrointestinal tract, leading to general edema, ascites, and pleural effusions. Case presentation A 71-year-old woman visited another hospital for evaluation of hypoalbuminemia and systemic edema. She was hospitalized for a close inspection of hypoalbuminemia and was diagnosed with PLGE. Steroid and azathioprine therapy was prescribed; however, hypoalbuminemia did not improve, and the patient’s condition worsened due to anasarca. As hospitalization was prolonged, the patient was transferred to our hospital. She was infected with Helicobacter pylori, and we performed H. pylori eradication. Following H. pylori eradication, her edema improved remarkably. Conclusion We present the first case wherein H. pylori eradication successfully improved protein leakage in the lower gastrointestinal tract in a patient diagnosed with PLGE complicated with refractory to immunosuppressant treatment. H. pylori eradication should be considered in patients with PLGE complicated with H. pylori infection, without specific endoscopic finding or refractory to immunosuppressants.
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Affiliation(s)
- Misako Tanaka
- Internal Medicine, Heisei Memorial Hospital, Kashihara, Nara, Japan.,Department of Gastroenterology, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, 634-8522, Japan.
| | - Ryuichi Noguchi
- Internal Medicine, Heisei Memorial Hospital, Kashihara, Nara, Japan
| | - Aritoshi Koizumi
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Akihiko Shibamoto
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Kosuke Kaji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Naotaka Shimozato
- Internal Medicine, Heisei Memorial Hospital, Kashihara, Nara, Japan.,Department of Gastroenterology, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Kuniyuki Kojima
- Internal Medicine, Heisei Memorial Hospital, Kashihara, Nara, Japan
| | | | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, 634-8522, Japan
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6
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Frittoli RB, Vivaldo JF, Costallat LTL, Appenzeller S. Gastrointestinal involvement in systemic lupus erythematosus: A systematic review. J Transl Autoimmun 2021; 4:100106. [PMID: 34179742 PMCID: PMC8214088 DOI: 10.1016/j.jtauto.2021.100106] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
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. Severe Gastrointestinal manifestations are rare, however potential life threatening. Vasculitis and thrombosis are the most frequent pathological mechanism described. Cohort studies with analysis of genetic risk factors and the role of autoantibodies could improve diagnosis and prognosis.
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Affiliation(s)
- Renan Bazuco Frittoli
- Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil
| | - Jéssica Fernandes Vivaldo
- Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
| | - Lilian Tereza Lavras Costallat
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil
| | - Simone Appenzeller
- Department of Medicine, School of Medical Science - State University of Campinas, Campinas, São Paulo, 13083881, Brazil.,Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil.,Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil.,Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
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7
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Peng L, Li Z, Xu D, Li M, Wang Y, Wang Q, Zhang S, Zhao J, Zeng X. Characteristics and Long-term Outcomes of Patients with Lupus-related Protein-losing Enteropathy: A Retrospective Study. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2020; 1:47-52. [PMID: 36465074 PMCID: PMC9524762 DOI: 10.2478/rir-2020-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/02/2020] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The long-term outcomes of patients with systemic lupus erythematosus (SLE)-related protein-losing enter-opathy (PLE) are unclear. This study was aimed to investigate the clinical characteristics and long-term outcomes of patients with SLE-related PLE. METHODS This retrospective cohort study enrolled 58 patients with SLE-related PLE who were admitted to our center from January 2000 to June 2016. The patients' baseline characteristics and follow-up data were analyzed, and the prognostic outcomes were survival and disease flares. The prognoses were analyzed using Kaplan-Meier curves, log-rank tests, and Cox regression models. Factors with values of P<0.05 were considered potential predictors. RESULTS Two-thirds of patients had intestinal symptoms, and 77.6% of patients had concomitant organ/system involvement, including serositis (77.6%), lupus nephritis (57.6%), neuropsychiatric lupus (10.3%), and hematological disorders (22.4%). Common abnormalities in the laboratory test results were hypocomplementemia (87.9%), anti-Sjögren syndrome antigen A antibodies (51.7%), and high total cholesterol levels (62.1%). Five flares were recorded in 47 patients. The 1-, 3-, and 5-year survival rates were 93.6%, 91.3%, and 88.4%, respectively. Infection was the cause of death in 60% of patients. High 24-hour urine protein level was an independent risk factor associated with death (P = 0.012). Severe hypoalbuminemia (<12 g/L) was a predictor of disease flares in SLE-related PLE (hazard ratio, 10.345; 95% confidence interval, 1.690-63.321). CONCLUSIONS Infection causes most of the deaths in patients with SLE-related PLE. High 24-hour urine protein level is an independent risk factor associated with death, and severe hypoalbuminemia is a predictor of disease flares.
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Affiliation(s)
- Liying Peng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Zhao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yanhong Wang
- Department of Epidemiology and Bio-statistics (YW), Institute of Basic Medical Science, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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8
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de Carvalho JF, Lerner A, Gonçalves CM, Shoenfeld Y. Sjögren syndrome associated with protein-losing enteropathy: case-based review. Clin Rheumatol 2020; 40:2491-2497. [PMID: 33145631 DOI: 10.1007/s10067-020-05487-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
Abstract
The association between Sjögren's syndrome (SS) and protein-losing enteropathy (PLE) was scarcly reported. To analyze the clinical, therapeutic, and outcome characteristics of patients with SS and PLE and also to delineate the potential mechanisms and pathways connecting the gut to SS targeted organ's pathology. Systematic screening was conducted using PubMed/MEDLINE, LILACS, SciELO, Web of Science, and Cochrane, dating 1980 to 2020. SS and PLE were the key words. Eighteen patients with SS and PLE were summarized. The patient's ages ranged between 20 and 88 years, and only 4 were males. Primary SS was observed in most cases. Anti-Ro was detected in 100% of the cases while anti-La was reported in 64% of them. The clinical manifestations were protein loss, edema of the lower limbs, pleural effusion, ascites, facial edema, anasarca, diarrhea, and weight loss. Among these clinical manifestations, edema of the lower limbs was the most severe. Albumin concentration was 0.9-3.4 g/dL which increased to 2.8-4.3 g/dL after treatment. Small bowel biopsy was performed in all of the cases. Concerning the therapy, all the patients received systemic glucocorticoids. All of them improved. The period of onset of improvement ranged from 3 weeks to 36 months (an average of 3 months). The early diagnosis and appropriate therapy of PLE in patients with anti-Ro positive SS and who present edema, anasarca, or hypoalbuminemia is vital for a beneficial outcome. An excellent clinical improvement in all the cases was observed when treated early enough by cortico-therapy, thus preventing patient's deterioration, complications, and reducing morbidity and potential mortality.
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Affiliation(s)
- Jozélio Freire de Carvalho
- Institute for Health Sciences from Federal University of Bahia, Rua das Violetas, 42, ap. 502, Pituba, Salvador, Bahia, Brazil.
| | - Aaron Lerner
- Chaim Sheba Medical Center, The Zabludowicz Research Center for Autoimmune Diseases, Tel Hashomer, Israel
| | | | - Yehuda Shoenfeld
- Chaim Sheba Medical Center, The Zabludowicz Research Center for Autoimmune Diseases, Tel Hashomer, Israel.,Saint Petersburg State University, St. Petersburg, Russia
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9
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Lupus-associated protein losing enteropathy (LUPLE) complicated by a hypercoagulable state and successfully treated with belimumab. Clin J Gastroenterol 2020; 13:771-774. [DOI: 10.1007/s12328-020-01186-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022]
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10
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Ozen A. CHAPLE syndrome uncovers the primary role of complement in a familial form of Waldmann's disease. Immunol Rev 2019; 287:20-32. [PMID: 30565236 DOI: 10.1111/imr.12715] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 08/31/2018] [Indexed: 12/17/2022]
Abstract
Primary intestinal lymphangiectasia (PIL) or Waldmann's disease was described in 1961 as an important cause of protein-losing enteropathy (PLE). PIL can be the sole finding in rare individuals or occur as part of a multisystemic genetic syndrome. Although genetic etiologies of many lymphatic dysplasia syndromes associated with PIL have been identified, the pathogenesis of isolated PIL (with no associated syndromic features) remains unknown. Familial cases and occurrence at birth suggest genetic etiologies in certain cases. Recently, CD55 deficiency with hyperactivation of complement, angiopathic thrombosis, and PLE (the CHAPLE syndrome) has been identified as a monogenic form of PIL. Surprisingly, loss of CD55, a key regulator of complement system leads to a predominantly gut condition. Similarly to other complement disorders, namely paroxysmal nocturnal and hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS), CHAPLE disease involves pathogenic cross-activation of the coagulation system, predisposing individuals to severe thrombosis. The observation that complement system is overly active in CHAPLE disease introduced a novel concept into the management of PLE; anti-complement therapy. While CD55 deficiency constitutes a treatable subgroup in the larger pool of patients with isolated PIL, the etiology remains to be identified in the remaining patients with intact CD55.
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Affiliation(s)
- Ahmet Ozen
- Division of Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey.,The Istanbul Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases, Istanbul, Turkey
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11
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Eguchi M, Iwanaga N, Sakai K, Michitsuji T, Tsuji Y, Kawahara C, Kobayashi H, Horai Y, Mori T, Izumi Y, Ito M, Kawakami A. Protein-losing gastroenteropathy in a patient with concomitant systemic lupus erythematosus and Sjögren's syndrome. Immunol Med 2019; 41:34-38. [PMID: 30938260 DOI: 10.1080/09114300.2018.1451614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
We report a female in her twenties who developed generalized edema. She was diagnosed as systemic lupus erythematous (SLE) and Sjögren's syndrome (SS) based on her physical manifestations and positive findings for antinuclear antibody and anti-SS-A/SS-B-antibody. Although she manifested hypoproteinemia, a possibility of lupus nephritis was denied due to a lack of significant abnormality in kidney function tests and urinalysis. The nature of hypoproteinemia and related symptoms was identified as protein losing gastroenteropathy (PLGE) based on α 1-antitrypsin clearance and histopathology findings. Physicians should be aware that PLGE may develop as an underlying cause of edema in SLE and SS.
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Affiliation(s)
- Mizuna Eguchi
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Nozomi Iwanaga
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan.,b Department of Rheumatology , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Kosuke Sakai
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Tohru Michitsuji
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Yoshika Tsuji
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan.,c Rheumatic and Collagen Disease Center , Sasebo Chuo Hospital , Sasebo , Nagasaki , Japan
| | - Chieko Kawahara
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Hitomi Kobayashi
- d Department of Gastroenterology , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Yoshiro Horai
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan.,b Department of Rheumatology , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan.,e Clinical Research Center , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Takahiro Mori
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Yasumori Izumi
- a Department of General and Internal Medicine , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Masahiro Ito
- e Clinical Research Center , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan.,f Department of Pathology , National Hospital Organization Nagasaki Medical Center , Omura , Nagasaki , Japan
| | - Atsushi Kawakami
- g Division of Advanced Preventive Medical Sciences, Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
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12
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Mafi M, Khodabandeh A, Riazi-Esfahani H, Mirghorbani M. Bilateral Central Serous Retinal Detachment in Protein-losing Enteropathy. KOREAN JOURNAL OF OPHTHALMOLOGY 2019; 33:577-578. [PMID: 31833258 PMCID: PMC6911787 DOI: 10.3341/kjo.2019.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/23/2019] [Accepted: 05/09/2019] [Indexed: 12/02/2022] Open
Affiliation(s)
- Mostafa Mafi
- Farabi Eye Hospital, Tehran University of Medical Science, Tehran, Iran
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13
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Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología. ACTA ACUST UNITED AC 2019; 15:3-20. [DOI: 10.1016/j.reuma.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
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14
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Jiajie Z, Shan L, Xiaolan S, Yu G, Yijie L, Jiande C, Qingguo W, Wei W. Protein losing enteropathy caused by eosinophilic gastroenteritis: A case report. J TRADIT CHIN MED 2018. [DOI: 10.1016/s0254-6272(18)30996-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Abstract
Gastrointestinal (GI) symptoms are common among patients with systemic lupus erythematosus (SLE), although only rarely are they caused by active organ system involvement from SLE itself. Rapid diagnosis and appropriate treatment of lupus enteritis and other GI manifestations of SLE are critical, because of the potential for organ and life-threatening complications. The 3 main variants of lupus enteritis are lupus mesenteric vasculitis, intestinal pseudo-obstruction, and protein-losing enteropathy. These GI manifestations and others in patients with SLE are reviewed here.
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Ahn SS, Jung SM, Song JJ, Park YB, Lee SW. Prognostic nutritional index is correlated with disease activity in patients with systemic lupus erythematosus. Lupus 2018; 27:1697-1705. [PMID: 30020022 DOI: 10.1177/0961203318787058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The prognostic nutritional index (PNI), which is calculated using serum albumin level and total lymphocyte count in the peripheral blood, is regarded as an index that reflects the immunonutritional status of patients. PNI was calculated in 217 systemic lupus erythematosus (SLE) patients according to the following formula: 10 × serum albumin value (g/dL) + 0.005 × peripheral lymphocyte count (/mm3). Pearson's correlation analysis was used to elucidate the correlation between continuous variables. Linear and logistic regression analyses were performed to assess the correlation between laboratory variables and SLE Disease Activity Index-2000 (SLEDAI-2 K) and to differentiate between active and inactive SLE. Ninety-three patients were classified as active SLE (SLEDAI-2 K ≥ 5) and 124 as inactive SLE. Patients with active SLE exhibited lower median PNI than those with inactive SLE (39.0 vs. 49.1, p < 0.001). Multivariable logistic regression analysis revealed PNI as an independent predictor of active SLE. Multivariable linear regression analysis revealed that PNI was significantly correlated with laboratory variables of SLEDAI-2 K, erythrocyte sedimentation rate, C-reactive protein and SLEDAI-2 K. Furthermore, in patients who switched from active to inactive SLE after treatment ( n = 55), PNI increased as disease activity improved ( p < 0.001), which suggests that PNI may be useful for estimating SLE activity.
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Affiliation(s)
- S S Ahn
- 1 Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S M Jung
- 1 Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J J Song
- 1 Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y-B Park
- 1 Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,2 Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S-W Lee
- 1 Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,2 Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kim TH, Choi YH, Kang LH, Kim HJ, Jang JH, So MW. A Case of Protein Losing Enteropathy as Only Clinical manifestation of Systemic Lupus Erythematosus. KOSIN MEDICAL JOURNAL 2017. [DOI: 10.7180/kmj.2017.32.1.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Protein losing enteropathy (PLE) due to systemic lupus erythematosus (SLE) is relatively uncommon. PLE may be appeared sequentially after the diagnosis of SLE or concurrently with SLE. In most of concurrent cases, PLE was diagnosed one of various symptoms of SLE. Cases of PLE as the initial and only clinical presentation of SLE have been rarely reported. We described a 30-year old woman with general edema and abdominal distension was diagnosed PLE after stool alpha 1 antitrypsin clearance test. Her symptoms were getting worse even though the treatment with intravenous albumin. She was finally diagnosed PLE associated with SLE by additional laboratory findings (positive antinuclear antibody and anti-dsDNA IgG and low C3, C4 and CH50). She was treated with high dose of steroids and her symptoms were improved.
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Villela A, Ferreira A, Dias E, Lovatti R. ENTEROPATIA PERDEDORA DE PROTEÍNAS NO LUPUS ERITEMATOSO SISTEMICO: RELATO DE CASO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Liao CY, Chien ST, Wang CC, Chen IH, Chiu HW, Liu MY, Lin CH, Ben RJ, Tsai MK. Sjögren's syndrome associated with protein losing gastroenteropathy manifested by intestinal lymphangiectasia successfully treated with prednisolone and hydroxychloroquine. Lupus 2015; 24:1552-6. [PMID: 26169478 DOI: 10.1177/0961203315596078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 06/18/2015] [Indexed: 11/17/2022]
Abstract
Protein-losing gastroenteropathy (PLGE), a rare manifestation of primary Sjögren's syndrome (SS), is characterized by profound edema and severe hypoalbuminemia secondary to excessive serum protein loss from the gastrointestinal tract and is clinically indistinguishable from nephrotic syndrome. We report a case of a 30-year-old Taiwanese woman with PLGE-associated SS. In addition to a positive Schirmer's test, she had eye-dryness, thirst, and high levels of anti-SSA antibodies, fulfilling SS criteria. PLGE diagnosis was highly appropriate given the clinical profile of hypoalbuminemia, hypercholesterolemia, pleural effusion, and ascites, with absent cardiac, hepatic, or renal disease. We were unable to perform technetium-99 m-labeled human serum albumin scintigraphy ((99m)Tc-HAS). However, the patient's edema and albumin level improved dramatically in response to a 3-month regime of oral prednisolone followed by oral hydroxychloroquine.
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Affiliation(s)
- C-Y Liao
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - S-T Chien
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - C-C Wang
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - I-H Chen
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - H-W Chiu
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - M-Y Liu
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - C-H Lin
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - R-J Ben
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - M-K Tsai
- Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
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