Acute acalculous cholecystitis as the initial manifestation of systemic lupus erythematous

Abstract

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.

Rare case of lupus enteritis presenting as colorectum involvement: A case report and review of literature

“…SLE patients are prone to thromboses and angeitis. Mesenteric inflammatory veno-occlusive disease is another rare cause of LE in patients, and it is detected on abdominal CT[ 2 ]. We considered that the angeitis may be the vital pathological features of our patient due to the marked improvement of the patient with hormone therapy.…”

“…It occurs in critically ill patients who are likely to have a worse prognosis. At present, we use large dose corticosteroid to treat patients of LE successfully as a strategy, leading to symptom improvement and the absence of complications related to infection[ 2 ]. Most cases of LE in SLE develop after the diagnosis of SLE, involving the small intestine.…”

Treatment of MDA5-positive dermatomyositis complicated by gangrenous cholecystitis with tofacitinib

“…In recent years, there have been many reports on the treatment of autoimmune diseases and infectious diseases with tofacitinib. Lee et al [ 12 ] reported on systemic lupus erythematosus with cholecystitis as the first manifestation. Tofacitinib is effective in the treatment of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Behcet's disease, systemic vasculitis and other diseases [ 13 ].…”

Is conservative management a safe approach for patients with acute acalculous cholecystitis presenting with an acute abdomen?

“…After identifying 671 articles, 153 articles involving 171 cases were eligible: 104 viral infection and 67 rheumatic disease AAC patients. [8,11–162] Viral infection types included: Epstein Barr virus, hepatitis virus, dengue virus, SARS-CoV-2 (COVID-19), human immunodeficiency virus, and cytomegalovirus. Rheumatic diseases included: systemic lupus erythematosus, adult-onset Still disease, Henoch-Schönlein purpura, polyarteritis nodosa, Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis), microscopic polyangiitis, temporal arteritis, Wegener granulomatosis (granulomatosis with polyangiitis), Kawasaki syndrome, systemic juvenile idiopathic arthritis, and juvenile dermatomyositis (Table 1).…”