P1868 - Cyclic Vomiting Syndrome in Systemic Lupus Erythematosus: A Diagnostic Conundrum and Therapeutic Success with Mycophenolate Mofetil

Mohammed Rifat Shaik, MBBS¹, Nishat Anjum Shaik, MBBS¹, Akshay Duddu, MD², Jamal Mikdashi, MD³, Robert Chow, MD, MBA¹, Shien Hu, MD^4
1University of Maryland Medical Center Midtown Campus, Baltimore, MD; ²Greater Baltimore Medical Center, Towson, MD; ³University of Maryland Medical Center, Baltimore, MD; ⁴University of Maryland School of Medicine, Baltimore, MD

Introduction: Cyclic vomiting syndrome (CVS) can present as a diagnostic challenge, especially when observed in patients with underlying systemic lupus erythematosus (SLE). This case report explores the manifestation of recurrent vomiting in a 38-year-old male patient with SLE, in the absence of typical CVS-associated risk factors such as migraines or cannabis use, and the subsequent successful management with mycophenolate.

Case Description/Methods: A 38-year-old male with a history of SLE on hydroxychloroquine, chronic pain syndrome, depression, and anxiety disorder presented with multiple episodes of nonbilious vomiting of one day duration. He had episodic vomiting for the past four years, with episodes occurring 3-4 times/year and would last for 4-5 days each time. In between these episodes, the patient would return to his baseline health. He had no recreational drug use.

Workup showed elevated dsDNA antibody levels (38 IU/mL) and low C3 (86 mg/dL) and C4 levels (6 mg/dL). CT abdomen revealed hypertrophy and thickening of the gastric folds. No evidence of cholecystitis or nephrolithiasis was found. EGD showed erythematous mucosa was found in the gastric body (Figure). However, the biopsy results showed no evidence of gastric inflammation. The patient was discharged and advised to follow up with his rheumatologist. He was initiated on mycophenolate, and subsequently, his cyclic vomiting syndrome improved, with no further hospital admissions for similar episodes. Six months later, his follow-up dsDNA titers decreased (14 IU/mL) and C3 and C4 levels normalized, indicating reduced disease activity.

Discussion: While CVS is commonly associated with migraines and chronic cannabis use, its occurrence with autoimmune disorders is rare. Only one case report so far reported an association of CVS with SLE. Our patient did not have a history of migraines or cannabis use, and initial investigations failed to reveal any underlying cause. The decrease in SLE disease activity upon initiation of mycophenolate therapy coincided with the cessation of vomiting episodes, suggesting a potential link between SLE and CVS. Therefore, it is important to consider CVS as a possible differential diagnosis in the context of episodic vomiting in patients with autoimmune disorders. Treatment involves symptomatic management and addressing the underlying autoimmune condition. Conversely, in young patients presenting with CVS without cannabis use or migraines, it is crucial to investigate for underlying autoimmune conditions.



Disclosures:


Mohammed Rifat Shaik, MBBS¹, Nishat Anjum Shaik, MBBS¹, Akshay Duddu, MD², Jamal Mikdashi, MD³, Robert Chow, MD, MBA¹, Shien Hu, MD⁴. P1868 - Cyclic Vomiting Syndrome in Systemic Lupus Erythematosus: A Diagnostic Conundrum and Therapeutic Success with Mycophenolate Mofetil, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.