Lupus with "thumb-prints," "targets," and "combs".

A 28-year-old woman was undergoing evaluation for proteinuria (urine protein/creatinine ratio=9.6 [normal<0.3]). Two days following kidney biopsy, she presented to the emergency department with abdominal pain, vomiting, and obstipation. In the previous 3 months, she had experienced frequent episodes of abdominal pain, which used to subside spontaneously. She also had a history of intermittent fever and passage of frothy urine. Examination revealed distended abdomen with rebound tenderness and absence of bowel sounds. Reduced breath sounds were noted over the infrascapular area on both sides. Laboratory test results were as follows: hemoglobin, 9 g/dL; total leukocyte count, 9779 cells/mm3; erythrocyte sedimentation rate (ESR), 76 mm in the first hour; positive anti-nuclear antibody (1:640, homogeneous); C3, 61 mg/dL; and C4, 8 mg/dL. An erect radiograph of the abdomen excluded any bowel perforation. Computed tomography of the chest and abdomen revealed pleural effusion on both sides with diffuse thickening and edema of the bowel wall giving rise to “thumb-printing” (Figure 1) and “target” sign (Figure 2). The mesenteric vasculature (“comb” sign) and ascites were accentuated (Figure 2). Kidney biopsy revealed Class IV lupus nephritis. The patient was diagnosed with systemic lupus erythematosus (SLE) with nephritis and mesenteric vasculitis and was treated with high-dose pulsed methylprednisolone followed by monthly pulses of intravenous cyclophosphamide and tapering doses of oral prednisolone. Her bowel symptoms improved remarkably after 4 days of treatment. At the 6-month follow-up, she was relieved of abdominal symptoms and her ESR and proteinuria had normalized. She was started on maintenance therapy with azathioprine (2 mg/kg).