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SCLEROSING MESENTRITIS FOLLOWED BY PLEURISY: A RARE PRESENTATION
Mohammad I. Anindo^*1, Eldrid Baez¹, Arnab Ray^2
1Internal Medicine , Ochsner Medical Center, New Orleans , LA; ²Gastroentrology , Ochsner Medical Center, New Orleans, LA

33-year-old male with insignificant past medical history presented with lower abdominal pain, nausea & vomiting for a week. Blood chemistries were only remarkable for elevated ESR & CRP without leukocytosis. CT Abdomen showed inflammation of the left retroperitoneum. Empiric antibiotics for colitis was started but his symptoms worsened & was eventually admitted to the hospital. Diagnostic colonoscopy was unremarkable. Repeat CT Abdomen with contrast demonstrated fat stranding. Sclerosing Mesentritis (SM) was suspected & prednisone with tamoxifen was started. His symptoms subsided in the next few days. 2 months later (while on tamoxifen) he presented again with lower abdominal pain & was found to have an incarcerated umbilical hernia. He underwent herniorrhaphy, during which a biopsy of the mesentery was taken. Biopsy demonstrated spindle cell process and fragments of mesothelial lined fibro adipose tissue indicative of reactive myofibroblastic proliferation. There was chronic inflammation & reactive mesothelial hyperplasia. Immunostaining for smooth muscle actin, desmin, S-100, CD68, Ki-67, beta-catenin, CD34, & cytokeratin AE1/AE3 were negative. CT Abdomen post-herniorrhaphy was notable for a small fluid collection in the periumbilical region and fat stranding. Redemonstration of inflammatory changes with biopsy results further raised suspicion of recurrence of SM. The patient was placed on Azathioprine (AZA) daily & his symptoms improved. Few months later, the patient was diagnosed with gallstones & underwent cholecystectomy during which no fibrosis was noted in the mesentery leading us to believe the SM had resolved. AZA was stopped for the surgery & AZA was not restarted as it had caused excessive fatigue. 5-week post procedure CT scan demonstrated recurrence of fat stranding around the transverse colon & anterior to the stomach. AZA was restarted. Patient remained asymptomatic and repeat CT after 3 months had no fat stranding. AZA was again stopped to avoid excessive fatigue. A week after stopping AZA, the patient developed pleuritic chest pain with shortness of breath & had a small pleural effusion. With an unremarkable infectious workup and no abdominal symptoms, patient underwent a complete rheumatologic investigation for the effusion. He was positive for homogeneous ANA with titers1:640. New pleurisy off immunosuppression & positive ANA raised concerns for an autoimmune disease. He was given steroids & was restarted on AZA. His symptoms improved over the next week & since restarting AZA, he had no recurrence of abdominal pain or pleural effusion. Our literature review yielded 3 case reports of patients with SM who developed pleurisy & was thought to have Systemic Lupus Erythamatosus (SLE). Disease remission with immunosuppression raises concern for SM being part of an autoimmune disease process & possibly being a rare manifestation of SLE.

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