Dados do Trabalho

Title

Colitis as an atypical initial presentation of Systemic Lupus Erythematosus in a 30 year old woman.

Background

Systemic Lupus Erythematosus (SLE) is more prevalent in woman with at least 6 for 1 man. SLE is difficult to diagnose, because its systemic pathogenesis, affecting any organ and leading to the individuality of symptoms. The gastrointestinal manifestations are uncommon at initial clinic, retarding the nosological elucidation.

Case report

Female, 30 years old, white, admitted for main complaint of "pain in the belly for 1 month". Anamnesis: holocranial headache associated with recent memory loss 4 months ago improving with analgesics, worsening 2 months ago, so started Naproxen and Venlafaxine. She referred weight loss without quantification associated with hyporexia and symmetrical arthralgia in feet, hands, wrist and elbow with inflammatory parameters. Patient evolved 1 month ago with progressive abdominal pain, diffuse, tight, worse in right hypochondrium, without irradiation or improvement factors, worsening with change of decubitus and intensity 9 (0-10). In addition, she noticed an evacuation episode, dark, with soft stools. In admission she was disoriented. In the clinical investigation, she also had tinnitus, xerostomia, painless ulcers in mucous membranes, cervical adenomegalies, darkened and foamed urine with bladder catheter demonstrating hematuria. At the physical examination, globose abdomen, distended, decreased airflow sounds, tense to the palpation and diffuse pain, without signs of peritonitis. Positive ANA with thick dotted nuclear pattern > 1/640, anti-SM 139.2 U / ml, anti-RNP 127.1 U / ml, C3 21n / dL, C8 8mg / dL, anti-RO 8U / ml, anti-LA 6.2U / ml, SHV 97mm / H, CRP 12.8mg /dL. Additionally, anemia and leukocytosis with predominance of segmented. Serologies were negative. Concluded the diagnosis of SLE. Investigation by image: hepatomegaly, ascites and marked gastric distension of intestinal loops were evidenced. The patient initiated Hydroxychloroquine and Prednisone with Ciprofloxacin and Metronidazole. Due to worsening of the condition, the medical team underwent alteration of antibiotic therapy and performed exploratory laparotomy, presenting chronic and erosive colitis, supported by histopathology, suggesting autoimmune etiology. An anastomosis was performed with ileocolectomy. There was dehiscence and abscess formation, leading to transverse colectomy, segmental enterectomy and Bruck ileostomy with abscess drainage and cavity lavage. Patient remained in intensive care unit until stabilization, being transferred to the infirmary, where she stayed for two months in antibiotic therapy and physiotherapy, being discharged later.

Conclusion

Gastrointestinal manifestations are not prevalent in the initial lupus, and an invaluable evaluation is necessary, aiming at an early diagnosis and rapid onset of therapy, in order to avoid high risk complications.