Kupelian Chloe, Bowen DeMarco, Huang Maria, Lee Begem, Lenzen Christiane, Rungvivatjarus Tiranun
Assistant Clinical Professor of Pediatrics, Division of Pediatric Hospital Medicine, University of California San Diego/Rady Children's Hospital, 3020 Children's Way, MC 5064, San Diego, CA, 92123, USA.
Assistant Clinical Professor of Pediatrics, Division of Pediatric Hospital Medicine and Complex Care, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, H4/464, Madison, WI, 53792, USA.
J Med Case Rep. 2025 Jul 31;19(1):377. doi: 10.1186/s13256-025-05451-4.
Systemic lupus erythematosus is a multisystem inflammatory disease with a broad range of clinical and serologic presentations. The heterogeneity of presentation poses diagnostic challenges for the clinician, and a high index of suspicion is required. Classification systems exist for both clinical and immunologic criteria; however, they may lack sensitivity in assisting with diagnosis of atypical presentations. We present a case of an initial presentation of systemic lupus erythematosus consisting of nonspecific gastrointestinal symptoms with clinical and immunologic findings that fluctuated with menstrual cycles.
A 15-year-old Hispanic female initially presented with 2 days of epigastric abdominal pain, non-bloody and non-bilious emesis, and diarrhea. There was no fever, rash, weight loss, arthralgias, or dysuria. Menses started 1 day prior to presentation. She was persistently hypertensive throughout her admission. She developed respiratory distress with supplemental oxygen requirement due to pleural effusions identified on chest x-ray. Computed tomography of the abdomen showed large-volume ascites. Extensive evaluation was negative for malignancy and cardiac, gastrointestinal, or infectious etiologies. She demonstrated hypocomplementemia, which self-resolved without intervention. She initially had proteinuria, which resolved after menstruation. She was discharged without a specific diagnosis as her clinical status improved. She presented 2 weeks later for recurrent symptoms at the start of her next menstrual cycle with hypocomplementemia and proteinuria that persisted after menses. Elevated 24-hour urine protein led to a kidney biopsy, which showed mesangial proliferative lupus nephritis class II. The patient was formally diagnosed with systemic lupus erythematosus.
We present a case of new onset systemic lupus erythematosus with initial gastrointestinal symptoms occurring and receding concomitantly with the patient's menstrual cycle. Interpretation of the urinalysis was complicated by active menses, and both hematuria and proteinuria initially resolved at the completion of her menstrual cycle. In addition, her symptoms and hypocomplementemia resolved without intervention, making the diagnosis more challenging with insufficient clinical criteria for systemic lupus erythematosus. Clinicians should maintain a high index of suspicion for autoimmune disorders, as symptoms may unfold over time. Although rare, systemic lupus erythematosus may initially present with gastrointestinal symptoms without other classic clinical findings. Absence of serologic criteria and spontaneous resolution of hypocomplementemia also add to the novelty of this case.
系统性红斑狼疮是一种多系统炎症性疾病，具有广泛的临床和血清学表现。临床表现的异质性给临床医生带来了诊断挑战，需要高度的怀疑指数。临床和免疫标准都有分类系统；然而，它们在协助诊断非典型表现时可能缺乏敏感性。我们报告一例系统性红斑狼疮的初始表现，其包括非特异性胃肠道症状，且临床和免疫表现随月经周期波动。
一名15岁的西班牙裔女性最初出现2天的上腹部腹痛、非血性非胆汁性呕吐和腹泻。无发热、皮疹、体重减轻、关节痛或排尿困难。月经在就诊前1天开始。她在住院期间一直高血压。由于胸部X光检查发现胸腔积液，她出现呼吸窘迫，需要补充氧气。腹部计算机断层扫描显示大量腹水。对恶性肿瘤以及心脏、胃肠道或感染性病因的广泛评估均为阴性。她出现低补体血症，未经干预自行缓解。她最初有蛋白尿，月经后消失。随着临床状况改善，她出院时未得到明确诊断。2周后，在她下一个月经周期开始时，她因复发症状再次就诊，出现低补体血症和月经后持续存在的蛋白尿。24小时尿蛋白升高导致进行肾活检，结果显示为II级系膜增生性狼疮性肾炎。该患者被正式诊断为系统性红斑狼疮。
我们报告一例新发系统性红斑狼疮病例，其初始胃肠道症状随患者月经周期出现和消退。月经活跃使尿液分析的解读复杂化，血尿和蛋白尿最初在月经周期结束时消失。此外，她的症状和低补体血症未经干预自行缓解，由于系统性红斑狼疮的临床标准不足，使得诊断更具挑战性。临床医生应高度怀疑自身免疫性疾病，因为症状可能随时间逐渐显现。虽然罕见，但系统性红斑狼疮最初可能仅表现为胃肠道症状而无其他典型临床发现。血清学标准缺失以及低补体血症自行缓解也增加了该病例的特殊性。
