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.