Pathologic quiz case: an unusual complication of systemic lupus erythematosus

Abdominal Pain in a Female with Lupus - Opening the Pandora's Box

Systemic lupus erythematosus (SLE) is an autoimmune disease that can involve multiple organ systems. The most common form of vasculitis seen in SLE is small vessel vasculitis. Aortitis in SLE or antiphospholipid syndrome is an extremely rare complication. Here, we present a 32-year-old female who presented with a history of prolonged abdominal pain, who was evaluated and diagnosed to have aortitis as an unusual involvement in SLE with secondary antiphospholipid antibody syndrome.

Aortitis is an under-recognized manifestation of antiphospholipid syndrome: A case report and literature review

Aortitis is a classic manifestation of large vessel vasculitis. Antiphospholipid syndrome (APS), sometimes known as Hughes syndrome, is an acquired autoimmune disorder that manifests clinically as recurrent venous or arterial thrombosis. Patients with APS may also suffer from various underlying diseases, most frequently systemic lupus erythematosus (SLE). Catastrophic antiphospholipid syndrome (CAPS) is a rare but serious complication of APS characterized by failure of several organs due to diffuse microcirculatory thrombi. Its main manifestations involve the kidneys, lungs, heart and central nervous system, and require early diagnosis and rapid therapeutic management. While APS can affect virtually any blood vessel, aortitis is not a known symptom of APS. We report the case of a 36-year-old patient with APS and SLE who presented with CAPS during pregnancy, with no concomitant SLE flare. The first manifestation of CAPS was aortitis, preceding renal, cardiac and haematological manifestations. The outcome was favourable with combined treatment including corticosteroids, anticoagulants, plasma exchange and rituximab. We then carried out a literature search for papers describing the presence of aortitis in APS and/or SLE. In the cases of aortic involvement identified in the literature, including another case of CAPS, the occurrence of aortitis in SLE, often associated with the presence of antiphospholipid antibodies/APS, suggests that aortitis should be considered as an under-recognized manifestation and potential non-criterion feature of APS.

Aortitis: An Unusual Inflammatory Complication of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can involve any organ system. Vasculitides are classified according to the predominant vessel involved such as large vessel, medium vessel, or small vessel vasculitis. Of these, Takayasu arteritis, Behcet's disease, relapsing polychondritis, and immunoglobulin G4 (IgG4)-related disease predominantly involve large vessels. The most common form of vasculitis seen in SLE is small vessel vasculitis. Aortitis in SLE is an extremely rare complication. This is a case report of a 21-year-old female patient with a history of SLE with overlap syndrome of primary biliary cirrhosis and autoimmune hepatitis associated with antiphospholipid syndrome (APS), who presented with a one-week history of left-back burning lumbar pain, radiating to the flank, which increased with changes in position associated with intermittent claudication. In the angiography images and the positron emission tomography (PET) scan, a hypometabolic left para-aortic oval image was noted, corresponding to the presence of a contained hematoma in an abdominal aorta rupture. Later, she underwent vascular surgery and hemodynamics, performing thoracoabdominal aortic reconstruction together with aortorenal bypass and left nephrectomy. Pathology fundings of the left kidney correspond with class IV lupus nephritis, and the resection sample of the thoracoabdominal aneurysm showed a marked thinning and fragmentation of elastic fibers, areas of fibrosis of the wall with severe IgG4 negative lymphoplasmacytic infiltrate in the immunohistochemical study, establishing the diagnosis of aortitis.

Lupus Aortitis Successfully Treated with Moderate-dose Glucocorticoids: A Case Report and Review of the Literature

Lupus aortitis is a rare and potentially life-threatening disorder. Previous studies have reported the utility of high-dose systemic glucocorticoids or surgery as the treatment, although there have been no related controlled trials. We herein report a 49-year-old woman with a 35-year history of systemic lupus erythematosus who was diagnosed with aortitis. Her symptoms and laboratory and imaging abnormalities rapidly resolved upon the administration of moderate-dose glucocorticoids. We subsequently performed a literature review of similar cases to identify the appropriate treatment and discuss these cases. A study of further cases will be needed to identify the characteristics of patients who would benefit from moderate-dose glucocorticoid therapy.

Large vessel vasculopathy in a patient with systemic lupus erythematosus: a case report

Background

Vasculopathy in systemic lupus erythematosus is a rare form of vascular involvement characterized by non-inflammatory vascular injury with the accumulation of immune complexes in the walls of the arteries, resulting in luminal narrowing. While previous reports have demonstrated vasculitis in the large vessels or vasculopathy in the small vessels, vasculopathy in large vessels has not yet been reported.

Case presentation

We present the case of a 43-year-old Japanese woman with peripheral large vessel vasculopathy associated with systemic lupus erythematosus. She presented a 7-year history of progressive headaches and intermittent claudication, although she had no atherosclerotic risk factors. Vascular ultrasonography and enhanced computed tomography showed multiple vascular stenoses and occlusion. The histological findings of her left temporal artery revealed narrowing of the lumen caused by intimal thickening without inflammatory cells and the deposition of immunoglobulin G, complement component 3, and fibrinogen in the wall of the intima. Beraprost and cilostazol improved arterial occlusion without immunosuppressive therapy.

Conclusions

Large vessel vasculopathy should be considered another potential cause of arterial stenoses and occlusion in patients with lupus when they have peripheral arterial disease despite having no atherosclerotic risk factors.

Aortic Atherosclerosis in Systemic Lupus Erythematosus

Aortic atherosclerosis (AoA) defined as intima-media thickening or plaques and aortic stiffness (AoS) also considered an atherosclerotic process and defined as decreased vessel distensibility (higher pulse pressure to achieve similar degree of vessel distension) are common in patients with SLE.

Immune-mediated inflammation, thrombogenesis, traditional atherogenic factors, and therapy-related metabolic abnormalities are the main pathogenic factors of AoA and AoS.

Pathology of AoA and AoS suggests an initial subclinical endothelialitis or vasculitis, which is exacerbated by thrombogenesis and atherogenic factors and ultimately resulting in AoA and AoS.

Computed tomography (CT) for detection of arterial wall calcifications and arterial tonometry for detection of increased arterial pulse wave velocity are the most common diagnostic methods for detecting AoA and AoS, respectively. MRI may become a more applicable and accurate technique than CT. Although transesophageal echocardiography accurately detects earlier and advanced stages of AoA and AoS, it is semi-invasive and cannot be used as a screening method.

Although imaging techniques demonstrate highly variable prevalence rates, on average about one third of adult SLE patients may have AoA or AoS.

Age at SLE diagnosis; SLE duration; activity and damage; corticosteroid therapy; metabolic syndrome; chronic kidney disease; and mitral annular calcification are common independent predictors of AoA and AoS. Also, AoA and AoS are highly associated with carotid and coronary atherosclerosis.

Earlier stages of AoA and AoS are usually subclinical. However, earlier stages of disease may be causally related or contribute to peripheral or cerebral embolism, pre-hypertension and hypertension, and increased left ventricular afterload resulting in left ventricular hypertrophy and diastolic dysfunction. Later stages of disease predisposes to visceral ischemia, aortic aneurysms and aortic dissection.

Even earlier stages of AoA and AoS have been associated with increased cardiovascular and cerebrovascular morbidity and mortality of SLE patients.

Aggressive non-steroidal immunosuppressive therapy and non-pharmacologic and pharmacologic interventions for control of atherogenic risk factors may prevent the development or progression of AoA and AoS and may decrease cardiovascular and cerebrovascular morbidity and mortality in SLE.

Aortic dissection complicated with hemothorax in an adolescent patient with systemic lupus erythematosus: case report and review of literature

OBJECTIVES

To report a young patient with systemic lupus erythematosus (SLE) complicated by aortic dissection. The relevant literature on the association of SLE and aortic dissection is reviewed.

METHODS

We describe an adolescent patient with childhood-onset SLE diagnosed aortic dissection with presentation of hemothorax. The literature review was performed by a PubMed search using the keywords systemic lupus erythematosus (SLE), aortic dissection, hemothorax, and carotid intima-media thickness (CIMT).

RESULTS

A 17-year-old male was admitted to the hospital for severe abdominal pain. His past medical history included childhood-onset SLE complicated with lupus nephritis. Acute aortic dissection complicated with hemothorax was diagnosed and he died despite medical therapy. The accelerated CIMT progression of our patient, 0.14 mm in 20 months, might suggest ongoing premature atherosclerotic changes in the aortic wall. On reviewing the English literature, 21 cases of aortic dissection in SLE have been analyzed and discussed. Patients younger than 40 years of age, hypertension, and long-term steroid use are common features of aortic dissection in SLE patients. The possible pathogenesis of aortic dissection in SLE includes atherosclerosis, degeneration, and vasculitis. The widely accepted CIMT measured by ultrasound could be a potential diagnostic tool to access the risk of cardiovascular events.

CONCLUSIONS

Aortic dissection is a rare complication of SLE, but could take place in an adolescent patient with childhood-onset disease. It is important to include aortic dissection as a differential diagnosis in SLE patients with unexplained sharp abdominal, chest, or back pain.

Aortitis and aortic thrombus in systemic lupus erythematosus

Aortitis is an uncommon complication of systemic lupus erythematosus (SLE). Most cases of lupus-associated aortitis have been described in conjunction with aortic aneurysms or aortic dissection and have been documented either at autopsy or during surgery to repair a dissection. We describe an unusual case of aortitis associated with an aortic thrombus in a young man with SLE.