Case Presentation: A 29-year-old Black female presented with abdominal pain, nausea, vomiting, and diarrhea. Her history was notable for a hospitalization three months prior for Streptococcus pneumoniae meningitis with associated septic arthritis of the hip requiring long term antibiotics. On examination she was afebrile with reassuring vital signs. Her abdomen was distended with notable diffuse abdominal tenderness and a positive fluid wave. Initial laboratory results revealed a WBC of 4.3×109/L, a non-anion gap metabolic acidosis, and 3+ proteinuria. Imaging revealed perihepatic and peri-splenic ascites and pelvic fluid, determined to be not amenable to paracentesis.Her labs and cultures showed no gastrointestinal or pelvic infection, so she was initially symptomatically treated for gastroenteritis with minimal improvement. On hospital day five, her pain had minimally improved and her exam revealed worsening distension. Her labs revealed worsening leukopenia, so a diagnostic paracentesis was performed demonstrating transudative ascites. This combined with a urine protein of 665 mg in 24 hours, raised concern for nephrotic ascites. Subsequent autoimmune labs showed an ANA titer of 1:1280 with positive SSA, SSB, and ds-DNA autoantibodies as well as hypocomplementemia. Rheumatology was consulted and she was diagnosed with lupus. Renal biopsy confirmed lupus nephritis class V.
Discussion: The protean nature of lupus poses a diagnostic challenge with its non-specific initial signs and symptoms and ‘flare’ nature. Presentations can vary and go beyond the classic malar rash and arthritis. This patient exhibited an unusual presentation of SLE, nephrotic ascites, in the setting of lupus nephritis.Lupus nephritis is a common manifestation of SLE, occurring in up to 40% of patients(1). LN is more common in non-white SLE patients, especially Black patients, and individuals with SLE and kidney involvement have higher mortality. However, this patient’s initial presentation was notable for ascites. Serositis is the presenting symptom in only 6% of SLE patients(2). Of SLE patients who have serositis either as an initial presentation or during their disease course, only 14% have ascites appreciable on physical exam(2).Of additional interest is our patient’s history of strep meningitis. Given her advanced lupus nephritis, it is probable that she had SLE at the time of her infection. Patients with SLE can have immunosuppression secondary to treatment or the disease itself. There have been case reports of severe infection as an initial presentation of SLE, primarily with encapsulated bacteria.
Conclusions: Known as the “great imitator”, lupus frequently presents a complex combination of diagnostic difficulty and a high potential for severity. As such, clinicians should have a high index of suspicion for SLE and consider it even in the face of atypical presenting symptoms such as ascites.