Discussion
SLE is a multisystem autoimmune disease in which deposition of immune
complexes and pathogenic autoantibodies lead to a wide variety of
symptoms (8). Abdominal pain in SLE patients can occur for multiple
reasons including severe lupus vasculitis presenting as gastrointestinal
perforation or mesenteric thrombosis, acute pancreatitis, cholecystitis,
lupus mesenteric vasculitis and hepatitis (9). Intussusception is a
condition in which the proximal segment of the intestine telescoping
into the distal part of it (10). Although, intussusception I uncommon in
adults and more likely to occur during childhood but adult have an
underlying pathology in approximately 90% of cases. An intussusception
in the small intestine mainly due to secondary causes, either due to
extraluminal or intraluminal lesions ( Meckel’s diverticulum, lymphoma,
lipoma, postoperative, adhesions and metastases), however,
intussusception in the large bowel is mostly due to malignant aetiology
(11). The surgical specimen can shows macroscopically aspects of
intussusception in the intestine (Figure 1) as well as the
microscopically histopathology features (Figure 2)
At usually computer tomography (CT) Scan for the abdomen can identify
the potential cause. The presence of bowel with bowel configuration with
or without the existence of adipose tissue and mesenteric vessels is
pathognomonic for intussusception (5).
The pathogenesis of the intussusception in our patient related to SLE
could be mostly the initial manifestation of the disease. Only seven
cases of intussusception in Patients with SLE have been described in the
literature. In four cases were secondary to lupus mesenteric vasculitis
(LMV) (7), one of them lymphadenopathy was the main cause, one was
related to Burkitt’s lymphoma, one was secondary to changes in the
peristalsis of oedematous small intestine (4, 7, 12, 13).
The first report has been published by Hermann (11), on a five years old
child with known who had an intussusception as a complication to LMV.
The exact pathology and mechanism of LMV causing intussusception is not
fully understood (4). A potential explanation is that vascular necrosis
occurred by diffuse vasculitis with partial devitalisation of the
intestinal segment, this can cause the interruption of the normal
neuromuscular function, with concomitant intussusception and possibility
of venous infarction necessitating bowel resection (4).
Intussusception is a very serious complication carrying a high mortality
rate (14), CT abdomen has a central role in early detection of LMV and
delivers a precise imaging of the lesions. However, the detection of the
underlying causative factor of the intussusception can be challenging
due to differentiation from bowel wall edema may not be possible (figure
3). In our case the CT abdomen of the patient Showed bilaterally pleural
effusion, moderate free peritoneal fluid collection (Ascites) and
rounded lumber mass with double layers suggestive of intussusception.
Another report described a known case of lupus with fungal infection
with intussusception. It is not fully clear whether there is an
association between these conditions (15). However, in our case
intussusception occur few days after the patient present complaining
from the rheumatological features.
In conclusion, a 40-year-old female presented with multiple joints pain,
skin rash, chest pain, hair loss and intussusception, bowel resection
was done and they found no evidence of malignancy, infection causes or
mesenteric vasculitis. Therefore, it is more likely that the
intussusception was a secondary cause to SLE in this patient.