The American College of Rheumatology (ACR) established eleven criteria in 1982, which were revised in 1997 as a classification tool for implementing SLE definitions in clinical trials [
3]. If a person has any 4 out of 11 symptoms, he is with SLE. In our case, the old male meets five criteria: (1) oral ulcer; (2) polyserositis including pleural effusion, ascites and, pericardial effusion; (3)anemia; (4) positive serology for antiphospholipid antibody and syphilis; (5) positive antinuclear antibody titer of 1:3200. From the above, the patient with SLE is clear. The multiple intestinal ulcers need differential diagnosis between CD and lupus enteritis. CD is a chronic and disabling inflammatory disease of the digestive system of unknown etiology. The incidence of CD is highest in the Northern Europe, more and more young people have been diagnosed CD in China recently [
4]. The diagnosis of CD is established by a combination of clinical symptoms, endoscopic appearance, radiology and histology. Chronic diarrhea is the most common symptom in CD. The most significant endoscopic features of CD are discontinuous involvement, anal lesions, and cobble stoning. CT is an imaging technique with the highest diagnostic accuracy for the detection of intestinal involvement and penetrating lesions in CD, the features of CD are dilation, tortuosity, prominence and wide spacing of mesentery with mesenteric arterial which called comb’s sign [
5]. Focal crypt irregularity and granulomas are the generally accepted pathological features. There are some aspects support CD: (1) chronic diarrhea; (2) marked thickening of the entire colonic mucosa; (3) pathological tend to CD. However, there are some opposed points: (1) old male and short disease course; (3) endoscopic appearance is not totally conformed to CD. There is no consistent definition of lupus enteritis. Some scholars believe that lupus enteritis is the basis of a series of processes, including intestinal vasculitis, mesenteric arteritis, abdominal serositis and lupus peritonitis [
6]. Most people think that lupus enteritis is vasculitis or inflammation of the intestinal tract. The most frequent symptoms were abdominal pain and diarrhea. CT and pathology have become the gold standard for diagnosis [
7]. Typical features include bowel dilation,bowel-wall thickening, abnormal bowel wall enhancement (target sign) [
8], engorgement of mesenteric vessels with an increased number of visible vessels (comb’s sign). These are nonspecific because the above-described abnormalities can also be seen in patients with pancreatitis, peritonitis or CD. There is no unified view about the endoscopic appearance of lupus enteritis, only one Chinese professor described “deep ulcer” in a case report of lupus enteritis. In our case, the ulcers of the terminal ileum and colon are similar to CD and “deep ulcer” in a few points. On the basis of diagnosis in patients with SLE, the endoscopic appearance was more inclined to lupus enteritis and treatment effect also confirmed this point. Whether SLE can cause gastrointestinal perforation nor not, less reported at present. Oshimo Y [
9] reported a case of the elderly man with SLE associated with paralytic ileus and fistula formation in 1999, our case is the first case of SLE with gastric-intestinal fistula.
The differentiation of CD from SLE gastrointestinal involvement may be difficult. In fact, cases with inflammatory bowel diseases like CD could show similar clinical signs and symptoms to SLE, and in some cases of CD might fulfill some of the classifications of criteria for SLE. With reference to the literature [
10], we listed the following differences between lupus-like Crohn’s from lupus enteritis (Table
1).
Table 1
The Differences between Lupus-like Crohn’s disease and Lupus Enteritis
Clinical Presentation | No specific (abdominal pain, diarrhea) | No specific (abdominal pain, nausea and vomiting) |
Abdominal CT scan | Comb’s sign, Segmental bowel stenosis | Comb’s sign, Target sign, Pseudoobstruction, Segmental bowel dilatation |
Endoscopy | Cobblestone changes, Segmental and jumping lesions | Multiple round- or oval-shaped discrete ulcers. |
Therapy | 5-ASA, Corticosteroids, Immunosuppressants, Biological agents | Corticosteroids, Immunosuppressants, |
Steroids are considered to be first-line therapy for lupus enteritis. Depending on the clinical state or other organ involvement, steroid administration may be intravenous or oral, preferably in the case of a severe lupus burst, as tissue edema caused by enteritis may reduce drug absorption [
11]. Hydroxychloroquine, azathioprine, mycophenolate mofetil could be considered for long-term maintenance treatment, although it is unclear whether recurrence can be prevented.
Here, we report a case of lupus enteritis masquerading as CD which indicated us there are some similar points between lupus enteritis and CD. Firstly, “comb’s sign” can be shown in CT of lupus enteritis or CD. Secondly, ganglion cell is not specific for the CD which can be seen in lupus enteritis. Lastly, the two diseases have similar clinical symptoms including abdominal pain and diarrhea. The endoscopic appearance of lupus enteritis is nonspecific, on the basis of our case, the features of lupus enteritis can be described as spacious, clean and no moss ulcers which discontinuous involved all gastrointestinal tract. More research and cases are needed to further identify the incidence, clinical manifestations, imaging characteristics and endoscopic appearance of lupus enteritis.