Abstract
Lupus protein-losing enteropathy (LUPLE) is a well reported but a rare manifestation of systemic lupus erythematosus (SLE). The main objectives of this study are to raise awareness of LUPLE that can be easily missed by internist, rheumatologist, gastroenterologist and nephrologist, and then to be considered in any patient with unexplained edema, ascites, and hypoalbuminemia. A systematic review was performed with 112 patients who met the eligibility criteria and were critically appraised. The LUPLE was ultimately diagnosed by either Tc-99m albumin scintography (99mTc-HAS) or fecal alpha-1-antitrypsin clearance test. Clinical features of patients, at the time of LUPLE diagnosis, were as follows: age was 34 ± 14.2 years; the female to male ratio was 5.8:1; the mean time to development of LUPLE after diagnosis of SLE was 4.19 ± 4.7 years. There was a predominance of Asian (64.7%) while 29.5% were white or Hispanic patients. Eighty percent had peripheral edema, 48% had ascites, 38% had pleural effusion, and 21% had pericardial effusion. Forty-six percent had diarrhea, 27% had abdominal pain, 22% had nausea, and 19% had vomiting. Hypoalbuminemia was the most common characteristic laboratory finding (96%). A 24-h urine protein was less than 0.5 gm in (71%). Almost all patients (96%) had positive ANA with predominant speckled patterns (55%) and hypocomplementemia (79%). Colonoscopy showed mucosal thickening in 44% of patients, and the majority of patients (52%) revealed no abnormalities; on the other hand, intestinal histology either revealed mucosal edema, inflammatory cell infiltrate, lymphangiectasia, mucosal atrophy or vasculitis in 80% of patients. All patients were started on steroids. Thirty-four percent responded to steroids alone. Sixty-six percent were started with other immunosuppressive therapies, which include cyclophosphamide (46%), azathioprine (33%), and a combination of cyclophosphamide and azathioprine (7%). A few reported cases responded to either cyclosporine or etanercept. Prognosis was very good with steroids combined with immunosuppressive therapy. This is the first systematic review of LUPLE and should be considered as an etiology of unidentified edema, ascites, and hypoalbuminemia.
Similar content being viewed by others
References
Pachas WN, Linscheer WG, Pinals RS (1971) Protein-losing enteropathy in systemic lupus erythematosus. Am J Gastroenterol 55(2):162–167
Trentham DE, Masi AT (1976) Systemic lupus erythematosus with a protein-losing enteropathy. JAMA 236(3):287–288
Tsukahara M, Matsuo K, Kojima H (1980) Protein-losing enteropathy in a boy with systemic lupus erythematosus. J Pediatr 97(5):778–780
Pereira AS, Pereira Filho RA, Trevisan MA, Magallanes AF (1980) Intestinal lymphangiectasia in systemic lupus erythematosus. Arq Gastroenterol 17(4):210–212
Weiser MM, Andres GA, Brentjens JR, Evans JT, Reichlin M (1981) Systemic lupus erythematosus and intestinal venulitis. Gastroenterology 81(3):570–579
Chase GJ, O’Shea PA, Collins E, Brem AS (1982) Protein-losing enteropathy in systemic lupus erythematosus. Hum Pathol 13(11):1053–1055
Takagi S, Oshimi K, Sumiya M, Gonda N, Kano S, Takaku F (1983) Protein-losing enteropathy in systemic lupus erythematosus. Am J Gastroenterol 78(3):152–154
Wood ML, Foulds IS, French MA (1984) Protein-losing enteropathy due to systemic lupus erythematosus. Gut 25(9):1013–1015
Monballyu J, Hauglustaine D, Geboes K, Desmet V, Michelsen P (1985) Protein-losing enteropathy in systemic lupus erythematosus. Digestion 31(4):243–246
Heck LW, Alarcon GS, Ball GV et al (1985) Pure red cell aplasia and protein-losing enteropathy in a patient with systemic lupus erythematosus. Arthritis Rheum 28(9):1059–1061
Castaneda S, Maidenhauen F, Herrero-Beaumont G, Yanez R (1985) Protein-losing enteropathy as the initial manifestation of systemic lupus erythematosus. J Rheumatol 12(6):1210–1212
Edmunds SE, Ganju V, Beveridge BR, French MA, Quinlan MF (1988) Protein-losing enteropathy in systemic lupus erythematosus (Review). Aust NZ J Med 18(7):868–871
Benner KG, Montanaro A (1989) Protein-losing enteropathy in systemic lupus erythematosus. Diagnosis and monitoring immunosuppressive therapy by alpha-1-antitrypsin clearance in stool. Dig Dis Sci 34(1):132–135
Kobayashi K, Asakura H, Shinozawa T, Yoshida S, Ichikawa Y, Tsuchiya M, Brown WR (1989) Protein-losing enteropathy in systemic lupus erythematosus. Observations by magnifying endoscopy. Dig Dis Sci 34(12):1924–1928 Review
Edworthy SM, Fritzier MJ, Kelly JK, McHattie JD, Sheffer EA (1990) Protein-losing enteropathy in systemic lupus erythematosus associated with intestinal lymphangiectasia. Am J Gastroenterol 85(10):1398–1402
Perednia DA, Curosh NA (1990) Lupus associated protein-losing enteropathy. Arch Intern Med 150(9):1806–1810 Review
Tanaka T, Damiao AO, Gabriel Junior A et al (1991) Protein-losing enteropathy in systemic lupus erythematosus. Rev Hosp Clin Fac Med Sao Paul 46(1):34–37 Review
Meulders Q, Michel C, Marteau P, Grnage JD, Mougenot B, Ronco P, Mignon F (1992) Association of chronic interstitial cystitis, protein-losing enteropathy and paralytic ileus with seronegative systemic lupus erythematosus: case report and review of the literature. Clin Nephrol 37(5):239–244 Review
Chung U, Oka M, Nakagawa Y et al (1992) A patient with protein-losing enteropathy associated with systemic lupus erythematosus. Intern Med 31(4):521–524 Review
Kashihara T, Fujimori E, Oki A et al (1992) Protein-losing enteropathy and pancreatic involvement in a case of connective tissue disease. Gastroenterol Jpn 27(2):246–251
Garcia-Consuegra J, Merino R, Alonso A, Goded F (1992) Systemic lupus erythematosus: a case report with unusual manifestations and favourable outcome after plasmapheresis. Eur J Pediatr 151(8):581–582
Kuroe K, Sawada Y, Fukushi M et al (1994) A case of protein-losing enteropathy in idiopathic thrombocytopenic purpura with decreased IgA. J Gastroenterol 29(3):349–356
Sunheimer RL, Finck C, Mortazavi S, McMahon C, Pincus MR (1994) Primary lupus associated protein-losing enteropathy. Ann Clin Lab Sci 24(3):239–242
Molina JF, Brown RF, Gedalia A, Espinoza LR (1996) Protein-losing enteropathy as the initial manifestation of childhood systemic lupus erythematosus. J Rheumatol 23(7):1269–1271
Hizawa K, Iida M, Aoyagi K et al (1998) Double-contrast radiographic assessment of lupus associated enteropathy. Clin Radiol 53(11):825–829
Miyata M, Yoshida M, Saka M, Kasukawa R (2000) Protein-losing gastroenteropathy in system lupus erythematosus: diagnosis with 99m Tc-human serum albumin scintigraphy. Arth Rheum 43(8):1900
Northcott KA, Yoshida EM, Steinbrecher UP (2001) Primary protein-losing enteropathy in anti-double-stranded DNA disease: the initial and sole clinical manifestation of occult systemic lupus erythematosus? J Clin Gastroenterol 33(4):340–341
Gornisiewicz M, Rodriguez M, Smith JK, Saag K, Alarcon GS (2001) Protein-losing enteropathy in a young African-American woman with abdominal pain, diarrhea and hydronephrosis. Lupus 10(12):835–840
Yoshida M, Miyata M, Saka M et al (2001) Protein-losing enteropathy exacerbated with the appearance of symptoms of systemic lupus erythematosus. Intern Med 40(5):449–453
Gattorno M, Buoncompagni A, Barabino A et al (2002) Severe hypoalbuminaemia in a systemic lupus erythematosus–like patient. Eur J Pediatr 161(2):84–86 Review
Lee CK, Han JM, Lee KN et al (2002) Concurrent occurrence of chylothorax, chylous ascites, and protein-losing enteropathy in systemic lupus erythematosus. J Rheumatol 29(6):1330–1333
Yazici Y, Erkan D, Levino DM, Parker TS, Lockshin MD (2002) Protein-losing enteropathy in systemic lupus erythematosus: report of a severe, persistent case and review of pathophysiology. Lupus 11(2):119–123 Review
Ossandon A, Bombardieri M, Coari G, Graziani G, Valesini G (2002) Protein-losing enteropathy in systemic lupus erythematosus: role of diet and octreotide. Lupus 11(7):465–466
Wu CC, Lin SH, Chu P, Lai JH, Chang DM, Lin YF (2004) An unrecognized cause of oedema in a patient with lupus nephritis protein-losing enteropathy. Nephrol Dial Transplant 19(8):2149–2150
Park JM, Ahn SY, Shin JI, Yun MJ, Lee JS (2004) A systemic lupus erythematosus patient with protein-losing enteropathy. Yonsei Med J 45(5):923–926
Werner de Castro GR, Appenzeller S, Bertolo MB, Costallat LT (2005) Protein-losing enteropathy associated with systemic lupus erythematosus response to cyclophosphamide. Rheumatol Int 25(2):135–138
Hung J, Wood CA, Woronik V, Vieira JM Jr, Barros RT (2006) Protein-losing gastroenteropathy in a patient with systemic lupus erythematosus and anti- phospholipid antibody syndrome simulating nephrotic syndrome. Nephrol Dial Transplant 21(7):2027–2028
Turkcapar N, Ozyuncu N, Cinar K, Ensari A, Kucuk O, Idilman R, Duman N, Ozden A (2006) A case of systemic lupus erythematosus presenting with protein- losing enteropathy. Turk J Gastroenterol 17(3):226–230
Mok CC, Ying KY, Mak A, To CH, Szeto ML (2006) Outcome of protein-losing gastroenteropathy in systemic lupus erythematosus treated with prednisolone and azathioprine. Rheumatol (Oxford) 45(4):425–429
Oh DC, Ng TM, Ho J, Leong KP (2006) Systemic lupus erythematosus with concurrent protein-losing enteropathy and primary sclerosing cholangitis: a unique association. Lupus 15(2):102–104
Zheng WJ, Tian XP, Li L, Jing HL, Li F, Zeng XF, Tang FL (2007) Protein-losing enteropathy in systemic lupus erythematosus: analysis of the clinical features of fifteen patients. J Clin Rheumatol 13(6):313–316
Wang YF, Tseng KC, Chiu JS, Chuang MH, Chung MI, Lai NS (2008) Outcome of surgical resection for protein-losing enteropathy in systemic lupus erythematosus. Clin Rheumatol 27(10):1325–1328
Kim YG, Lee CK, Byeon JS, Myung SJ, Oh JS, Nah SS, Moon HB, Yoo B (2008) Serum cholesterol in idiopathic and lupus-related protein-losing enteropathy. Lupus 17(6):575–579
Waldman T (1976) Protein-losing gastroenteropathies. In: Bockus HKL (ed) Gastro-enterology, vol 2, 3rd edn. Philadelphia, Saunders, pp 361–385
Takeda H, Abe Y, Ajitsu S et al (1989) Protein-losing gastroenteropathy with antinuclear antibody and thrombocytopenia. Am J Gastroenterol 84:1332–1334
Tsutsumi A, Sugiyama T, Matsumura R, Sueishi M, Takabayashi K, Koike T (1991) Protein-losing enteropathy associated with collagen disease. Ann Rheum Dis 50:178–181
Chiu NT, Lee BF, Hwang SJ, Chang JM, Liu GC, Yu HS (2001) Protein-losing enteropathy diagnosis with (99m) Tc-labeled human serum albumin scintigraphy. Radiology 219(1):86–90
Chang JM, Hwang SJ, Chen HC, Lai YH (2002) Edema due to protein-losing enteropathy-a disorder rarely considered by nephrologists. Clin Nephrol 57(5):392–397
Wang SJ, Tsai SC, Lan JL (2000) Tc-99m Albumin Scintigraphy to monitor the effect of treatment in protein-losing gastroenteropahy. Clin Nuclear Med 25(3):197–199
Stielfelhagen P (2008) Why is the patient losing proteins via the intestines? MMWFortschr Med 148(16):13 German. No abstract available
Azais-Noblinski B, Liscia G, Tubiana JM, Marsot-Supuch K (1988) Acute systemic lupus erythematosus associated with exudative enteropathy. Apropos of a case. Review of the literature. Ann Radiol (Paris) 31(3):183–187 Review. French. No abstract available
Viallard JF, Fach J, Mercie P, Leng B, Pellegrinn JL (1998) Longy-Boursier M. Ann Med Interne (Paris) 149(8):485–491 Review. French
Marteau P, Grange JD, Michel C et al (1990) Exudative enteropathy and interstitial cystitis due to systemic lupus erythematosus. Gastroenterol Clin Biol 14(10):771–775 French
M’Rad S, Thi Le, Huong D, Bletry O et al (1990) Ann Med Interne (Paris) 141(3):273–275 Review. French. No abstract available
Takahashi H (2001) Gastrointestinal complications of collagen vascular diseases. Nihon Rinsho Meneki Gakkai Keishi 24(3):112–124 Review. Japanese
Dupont E, Cleuziou A, Gendre JP, Cenac A (2002) Early and lasting remission of protein-losing enteropathy with corticosteroids. Presse Med 31(23):1081–1082 French
Houman MH, Ben Hassine L, Lamlourn M, Khedher I, Haouet S, Miled M (1997) Protein-losing enteropathy associated with systemic lupus erythematosus. Tunis Med 75(2):81–85 French
Matsumura M, Tanaka N, Sumili M et al (1996) Case of systemic lupus erythematosus with protein-losing gastroenteropathy. Nippon Naika Gakkai Zasshi 85(7):1150–1153 Review. Japanese
Murao S, Taooka Y, Yamanishi Y et al (1994) Protein-losing enteropathy and cerebral infarction associated with systemic lupus erythematosus. Ryumachi 34(1):59–63 Japanese
Pelletier S, Ekert P, Landi B, Coutellier A, Bletry O, Herson S (1992) Exudative enteropathy in disseminated lupus erythematosus. Ann Gastroterol Hepatol (Paris) 28(6–7):259–262 French
Ziza JM, Bletry O, Wechsler B et al (1986) Digestive manifestations in disseminated lupus erythematosus. Ann Gastroenterol Hepatol (Paris) 22(1):27–32 Review. French
Nakajima A, Ohnishi S, Mimura T et al (2000) Protein-losing enteropathy associated with hypocomplementemia and anti-nuclear antibodies. J Gastroenterol 35:627–630
Aoki T, Noma N, Takajo I et al (2002) Protein-losing gastropathy associated with autoimmune disease: successful treatment with prednisolone. J Gastroenterol 37:204–209
Ishige T, Kaneko H, Suzuki T et al (2008) Pemphigus vulgaris as a possible cause of protein-losing gastroenteropathy: a case report. J Paediatr Child Health 44:143–145
Acknowledgments
I would like to acknowledge the intense support and contribution of my research assistant Dr. Najma Khalil, Dr. Hamdani, Mr. Karim as well as the secretarial assistance of S. Seno and Joann Octubre. I would also like to extend my thanks to Faculty of Medicine at King Saud University.
Conflict of interest
We declare that we have no conflict of interest and Ethical committee has approved this study.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Al-Mogairen, S.M. Lupus protein-losing enteropathy (LUPLE): A systematic review. Rheumatol Int 31, 995–1001 (2011). https://doi.org/10.1007/s00296-011-1827-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00296-011-1827-9