Protein-Losing Enteropathy as the First Presentation of Systemic Lupus Erythematosus in a Resource-Limited Setting in Sri Lanka: A Case Report

Protein-losing enteropathy (PLE) is one of the rare gastrointestinal manifestations of systemic lupus erythematosus (SLE), which can manifest several years before the diagnosis of SLE. PLE should be suspected in patients with hypoalbuminemia in the absence of urinary protein loss and normal liver functions without any other manifestations of malnutrition. Due to the non-specificity of the imaging and histological findings, it is difficult to diagnose PLE in resource-limited settings. Thus, it is underdiagnosed. We report the case of a 38-year-old Sri Lankan (South Asian) female who is a diagnosed patient with hypothyroidism and has presented with worsening generalized body swelling and ascites for two months. She had hypoalbuminemia without proteinuria. Thus, the clinical diagnosis of PLE was suspected. The diagnosis of SLE was suspected because of significant alopecia, high titer (1:1000) antinuclear antibody (ANA) positivity, and hypocomplementemia. Though confirmatory tests such as Tc-99 albumin scintigraphy and stool alpha-1 anti-trypsin were not available in our resource-limited setting, the diagnosis of the SLE-associated protein -losing enteropathy was made as the patient fulfilled the European Alliance of Associations for Rheumatology (EULAR) criteria for SLE and also by excluding all the other possible causes of PLE.