Introduction: Ascites is an exceedingly rare initial presentation of systemic lupus erythematosus (SLE). Hallmarked by its varied clinical presentation, this multisystem inflammatory disease represents a diagnostic challenge. We present a rare case of acute onset ascites as the presenting symptom of lupus peritonitis (LP) in an adult male.
Case: A 57-year-old male with history of Grave's disease presents with progressive abdominal distension over three weeks. He reported early satiety, occasional non-bloody emesis, and weight loss during this time. Patient denied fevers, chills, and night sweats. Past medical history significant for alcohol abuse, but was not currently drinking. He was a prior smoker with history of incarceration.
On physical examination, patient was afebrile and normotensive. He was cachectic with temporal wasting and a tightly distended abdomen with flank dullness and positive fluid wave. No stigmata of chronic liver disease were evident. Abdominal ultrasound confirmed the presence of ascites without evidence of cirrhosis or portal vein thrombosis.
Remarkable serum labs demonstrated leukopenia, positive ANA (1: 2560), positive dsDNA (>1000 IU/ml), positive anti-smith antibody, and low complement. Diagnostic paracentesis yielded serum-ascitesalbumin gradient (SAAG 0.8 g/dL), negative adenosine deaminase, and negative cultures including culture for acid fast bacilli.
Patient was diagnosed with LP and started on treatment.
Discussion: Tense ascites is an exceedingly rare initial presentation of SLE. While serositis, most commonly pericarditis and pleuritis, develops in approximately 13% of patients with SLE during the course of the disease, peritoneal serositis is an uncommon clinical manifestation and extremely rare initial presentation of SLE.
In this case, the SAAG played an important role in identifying the possible etiologies of his ascites. In accordance with the Systemic Lupus International Collaborating Clinics (SLICC), our patient met criteria for SLE based serologic criteria, lymphopenia, and serositis. Our patient was treated with methylprednisolone and transitioned to oral prednisone taper, mycophenalate mofetil, hydroxychloroquine with significant clinical response.
The heterogenous and varied presentation of SLE exemplifies the diagnostic challenge to internists. LP is a unique presentation of gastrointestinal SLE and should be considered in the patient with refractory, massive ascites with low SAAG (< 1.1 g/dL).