Background and aims We describe a rare case of GI vasculitis flare in SLE presenting as diarrhoea, hematochezia and profound hypoalbuminemia.

Methods Case report

Results A 49 year old patient has had stable SLE in the past 22 years until she developed episodes of diffuse abdominal pains accompanied by alternating diarrhoea with constipation for 12 months; colonoscopy showed rectal ulcers and abdominal CT scan showed colonic diverticulosis. She received supportive therapy with only minimal relief. She was first admitted due to severe abdominal pain and worsening diarrhoea; laboratory tests disclosed thrombocytopenia, hypocomplementemia and high titer anti-dsDNA; there was dramatic resolution of symptoms with high dose corticosteroid and she was discharged significantly improved. A few weeks later while on tapering prednisone, she was re-admitted because of recurrence of profuse diarrhoea with severe electrolyte imbalance. Hospital course was marked by diarrhoea, severe hypoalbuminemia with progressive anasarca requiring intravenous albumin infusions, and episodes of massive hematochezia requiring multiple blood transfusions. Colonoscopy showed ischaemic colitis with edematous friable recto-sigmoid mucosa. Intravenous corticosteroid was increased. She underwent abdominoperineal resection with ileal resection of necrotic intestinal segments; histopath confirmed haemorrhagic gangrenous necrosis of the small intestine and colon, with small and medium vessel vasculitis and thrombosis. Although immediate post-operative course was uneventful, she succumbed a few days later to fulminant bacterial peritonitis due to anastomotic failure with extension of the bowel ischemia.

Conclusions This case illustrates the diagnostic dilemma and management challenges of lupus mesenteric vasculitis, requiring intensive monitoring for complications with aggressive supportive and disease-specific measures.