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Urinary tract involvement in systemic lupus erythematosus: Coexistence with lupus mesenteric vasculitis or intestinal pseudo-obstruction?
Author's Accepted Manuscript
Urinary tract involvement in systemic lupus erythematosus: coexistence with lupus mesenteric vasculitis or intestinal pseudo-obstruction? Danyi Xu, Jin Lin
www.elsevier.com/locate/semarthrit
PII: DOI: Reference:
S0049-0172(14)00112-7 http://dx.doi.org/10.1016/j.semarthrit.2014.05.018 YSARH50825
To appear in:
Seminars in Arthritis and Rheumatism
Cite this article as: Danyi Xu, Jin Lin, Urinary tract involvement in systemic lupus erythematosus: coexistence with lupus mesenteric vasculitis or intestinal pseudo-obstruction?, Seminars in Arthritis and Rheumatism, http://dx. doi.org/10.1016/j.semarthrit.2014.05.018 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Urinary tract involvement in systemic lupus erythematosus： coexistence with lupus mesenteric vasculitis or intestinal pseudo-obstruction? We read with great interest the recent article by Shiwen et al.［1］ evaluating the clinical characteristics of lupus mesenteric vasculitis (LMV) and demonstrated the frequent coexistence of the urinary tract involvement and LMV in systemic lupus erythematosus (SLE) patients of which maybe represented a subset of LMV. However，we consider that the coexistence of the urinary tract involvement (ureterohydronephrosis and/or interstitial cystitis) and LMV may be controversial. In this study, a dual diagnosis of lupus cystitis and LMV was observed in 22 cases (22/97, 22.7%), we suppose if these cases should be patients of intestinal pseudo-obstruction (IPO) or LMV overlap with IPO, which is another major gastrointestinal（GI） manifestation in SLE. Up to now, reviews［2,3］ on GI manifestation in SLE didn't support the coexistence of the urinary involvement and LMV in SLE. However， ureterohydronephrosis and/or interstitial cystitis were highly associated with IPO reported in more reports and reviews. About 63.3~84.6%［2,3］
IPO patients occur concurrently with ureterohydronephrosis and/or cystitis. Though vasculitis may be the common immune basis of LMV，IPO， ureterohydronephrosis and/or interstitial cystitis，further pathogenesis and pathological mechanisms are different. IPO and ureterohydronephrosis and/or interstitial cystitis both reflect the dysmotility of the visceral smooth muscle presenting as obstruction of intestinal and urinary tract, primary myopathy or neurogenic pathology, secondary to either vasculitis or autoantibodies against smooth muscle may be the same pathogenesis mechanism［2］. However，LMV should be classified into ischaemic enteritis secondary to infammatory vasculitis or thrombosis of the intestinal vessels，and it may eventually progress to bowel infarction with bleeding and/or perforation［2］. The definition of LMV is still ambiguous and a number of terms have been used to describe LMV, including mesenteric arteritis, lupus enteritis, lupus arteritis, lupus vasculitis and so on. Up to now, there is no definite diagnostic criterias for LMV and the diagnosis of LMV mainly relies on abdominal computed tomography (CT) scan. The common CT findings in mesenteric ischemia include dilated bowel, focal or diffuse
bowel wall thickening, abnormal bowel wall enhancement (double halo or target sign), mesenteric edema, engorged mesenteric vessels, and ascites［4］. The lack of specificity of these signs, however, is a limitation of the CT study because they can be seen in patients with pancreatitis, mechanical bowel obstruction, peritonitis, or inflammatory bowel disease, all of which may mimic intestinal ischemia clinically［4］. The inclusion criteria Shiwen et al. suggested also relied on CT findings，unfortunately there was no exclusion criteria to excluding possible complications like IPO, pancreatitis，peritonitis，inflammatory bowel disease and splenic infarct, therefore the diagnosis specificity might be limited. It is questionable that 39 patients (40.2%) with clinical manifestation of intestinal obstruction were included by Shiwen et al., which should be an uncommon symptom in LMV. So we suppose if patients of IPO or LMV overlap with IPO might be inappropriately included in this study，which explained the concurrent involvements of ureterohydronephrosis and/or interstitial cystitis. Besides，since the subjectivity in the interpretation of the various ischemic signs in CT，it would be better if an expert radiologist could take part in this study［5］.
GI manifestations are common and important in patients with SLE， however，far less attention was paid than the other major organ involvements. Further investigations are necessary to prove the coexistence of the urinary tract involvement and LMV as a subset. Reference： ［1］
Yuan S, Ye Y, Chen D, Qiu Q, Zhan Z, Lian F et al.. Lupus mesenteric vasculitis: Clinical features and associated factors for the recurrence and prognosis of disease. Semin Arthritis Rheum 2013 Nov 12. pii: S0049-0172(13)00248-5.
［2］
Tian XP, Zhang X. Gastrointestinal involvement in systemic lupus erythematosus: insight into pathogenesis, diagnosis and treatment. World J Gastroentero 2010;16:2971-7.
［3］
Chng HH, Tan BE, Teh CL, Lian, TY. Major gastrointestinal manifestations in lupus patients in Asia: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy. Lupus 2010;19:1404-13.
［4］
Taourel PG, Deneuville M, Pradel JA, Regent D, Bruel JM. Acute mesenteric ischemia:diagnosis with contrast-enhanced CT. Radiology 1996;199:632–6.
［5］
Frager D, Baer JW, Medwid SW, Rothpearl A, Bossart P. Detection of intestinal ischemia in patients with acute small-bowel obstruction due to adhesions or hernia:efficacy of CT. AJR 1996;166:67–71.
Urinary tract involvement in systemic lupus erythematosus: coexistence with lupus mesenteric vasculitis or intestinal pseudo-obstruction? Danyi Xu, Jin Lin
www.elsevier.com/locate/semarthrit
PII: DOI: Reference:
S0049-0172(14)00112-7 http://dx.doi.org/10.1016/j.semarthrit.2014.05.018 YSARH50825
To appear in:
Seminars in Arthritis and Rheumatism
Cite this article as: Danyi Xu, Jin Lin, Urinary tract involvement in systemic lupus erythematosus: coexistence with lupus mesenteric vasculitis or intestinal pseudo-obstruction?, Seminars in Arthritis and Rheumatism, http://dx. doi.org/10.1016/j.semarthrit.2014.05.018 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Urinary tract involvement in systemic lupus erythematosus： coexistence with lupus mesenteric vasculitis or intestinal pseudo-obstruction? We read with great interest the recent article by Shiwen et al.［1］ evaluating the clinical characteristics of lupus mesenteric vasculitis (LMV) and demonstrated the frequent coexistence of the urinary tract involvement and LMV in systemic lupus erythematosus (SLE) patients of which maybe represented a subset of LMV. However，we consider that the coexistence of the urinary tract involvement (ureterohydronephrosis and/or interstitial cystitis) and LMV may be controversial. In this study, a dual diagnosis of lupus cystitis and LMV was observed in 22 cases (22/97, 22.7%), we suppose if these cases should be patients of intestinal pseudo-obstruction (IPO) or LMV overlap with IPO, which is another major gastrointestinal（GI） manifestation in SLE. Up to now, reviews［2,3］ on GI manifestation in SLE didn't support the coexistence of the urinary involvement and LMV in SLE. However， ureterohydronephrosis and/or interstitial cystitis were highly associated with IPO reported in more reports and reviews. About 63.3~84.6%［2,3］
IPO patients occur concurrently with ureterohydronephrosis and/or cystitis. Though vasculitis may be the common immune basis of LMV，IPO， ureterohydronephrosis and/or interstitial cystitis，further pathogenesis and pathological mechanisms are different. IPO and ureterohydronephrosis and/or interstitial cystitis both reflect the dysmotility of the visceral smooth muscle presenting as obstruction of intestinal and urinary tract, primary myopathy or neurogenic pathology, secondary to either vasculitis or autoantibodies against smooth muscle may be the same pathogenesis mechanism［2］. However，LMV should be classified into ischaemic enteritis secondary to infammatory vasculitis or thrombosis of the intestinal vessels，and it may eventually progress to bowel infarction with bleeding and/or perforation［2］. The definition of LMV is still ambiguous and a number of terms have been used to describe LMV, including mesenteric arteritis, lupus enteritis, lupus arteritis, lupus vasculitis and so on. Up to now, there is no definite diagnostic criterias for LMV and the diagnosis of LMV mainly relies on abdominal computed tomography (CT) scan. The common CT findings in mesenteric ischemia include dilated bowel, focal or diffuse
bowel wall thickening, abnormal bowel wall enhancement (double halo or target sign), mesenteric edema, engorged mesenteric vessels, and ascites［4］. The lack of specificity of these signs, however, is a limitation of the CT study because they can be seen in patients with pancreatitis, mechanical bowel obstruction, peritonitis, or inflammatory bowel disease, all of which may mimic intestinal ischemia clinically［4］. The inclusion criteria Shiwen et al. suggested also relied on CT findings，unfortunately there was no exclusion criteria to excluding possible complications like IPO, pancreatitis，peritonitis，inflammatory bowel disease and splenic infarct, therefore the diagnosis specificity might be limited. It is questionable that 39 patients (40.2%) with clinical manifestation of intestinal obstruction were included by Shiwen et al., which should be an uncommon symptom in LMV. So we suppose if patients of IPO or LMV overlap with IPO might be inappropriately included in this study，which explained the concurrent involvements of ureterohydronephrosis and/or interstitial cystitis. Besides，since the subjectivity in the interpretation of the various ischemic signs in CT，it would be better if an expert radiologist could take part in this study［5］.
GI manifestations are common and important in patients with SLE， however，far less attention was paid than the other major organ involvements. Further investigations are necessary to prove the coexistence of the urinary tract involvement and LMV as a subset. Reference： ［1］
Yuan S, Ye Y, Chen D, Qiu Q, Zhan Z, Lian F et al.. Lupus mesenteric vasculitis: Clinical features and associated factors for the recurrence and prognosis of disease. Semin Arthritis Rheum 2013 Nov 12. pii: S0049-0172(13)00248-5.
［2］
Tian XP, Zhang X. Gastrointestinal involvement in systemic lupus erythematosus: insight into pathogenesis, diagnosis and treatment. World J Gastroentero 2010;16:2971-7.
［3］
Chng HH, Tan BE, Teh CL, Lian, TY. Major gastrointestinal manifestations in lupus patients in Asia: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy. Lupus 2010;19:1404-13.
［4］
Taourel PG, Deneuville M, Pradel JA, Regent D, Bruel JM. Acute mesenteric ischemia:diagnosis with contrast-enhanced CT. Radiology 1996;199:632–6.
［5］
Frager D, Baer JW, Medwid SW, Rothpearl A, Bossart P. Detection of intestinal ischemia in patients with acute small-bowel obstruction due to adhesions or hernia:efficacy of CT. AJR 1996;166:67–71.