systemic lupus erythematosus ( sle ) is an autoimmune inflammatory disease characterized by the presence of a plethora of autoantibodies and immune complex formation targeted to various organs of the body . anemia in sle is multi - factorial and can be part of the disease process or a complication of the treatment itself . autoimmune hemolytic anemia ( aiha ) is often associated with thrombocytopenia , lupus nephritis , and central nervous system activity . in comparison , common gastrointestinal ( gi ) manifestations of sle are non - specific and reflect either lupus of the gi tract or the effects of medication . serious gastrointestinal manifestations of sle can include mesenteric vasculitis , acute pancreatitis and intestinal pseudo - obstruction . this report describes a rare combination of hematological and gastrointestinal complication found in a patient with sle flare . a 22-year - old woman came to the emergency department of the king fahad medical city in riyadh , a tertiary care center in saudi arabia , presenting with history of acute abdominal pain of 2 days duration . she had also had two episodes of non - bilious vomiting she had been diagnosed as suffering from sle ( american college of rheumatology acr , criteria 5/11 ) 5 years prior to the current presentation , but had discontinued treatment of her own volition . on examination she showed stable vitals , with mild epigastric tenderness and no organomegaly . she had a hemoglobin of 9.8 g / dl , a leucocytic count of 11,500 and a platelet count of 11010 . she was managed as a case of acute pancreatitis , was kept nil per mouth and was given normal saline intravenously . she had a normal hepatobiliary system , and her serum lipids and serum calcium levels were also normal . on further evaluation , it appeared that she had an elevated esr 66 mm/1 hr . her antinuclear antibody ( ana ) levels were elevated 1:60 ( reference 1:35 iu / ml ) , as were her double stranded dna ( dsdna ) levels ( > 19 au / ml ) . during the hospital she had no bleeding , and further evaluation was suggestive of acute hemolysis ( positive direct coombs test , indirect hyper - bilirubinemia 8.6 g / dl , corrected retic count of 4% , elevated serum lactate dehydrogenase ( ldh ) 822 she has been asymptomatic for the past 2 years , and is regularly attending our clinic . the diagnosis of acute pancreatitis is an important differential in the evaluation of abdominal pain in a patient with sle . several factors have been implicated in the pathogenesis of this condition , such as vasculitis , drugs and antiphospholipid antibodies . the role of corticosteroids as an etiologic factor remains controversial . recently , data on 4,053 sle patients from china showed the overall prevalence of pancreatitis to be 0.67% , an annual incidence of 0.56% with a mortality rate of 37.04% . the authors of this study concluded that a combination of sle activity and multiple organ system involvement were predictors both of severity and mortality due to acute pancreatitis in sle patients . in this study , further glucocorticoid treatment was considered to lead to a better outcome in a majority of sle patients . the index case had been diagnosed with sle 5 years prior to her current presentation and she had discontinued treatment of her own accord . it is quite possible that , in her case , stopping the maintenance dose of steroids was responsible for both the acute pancreatitis and the acute autoimmune hemolytic anemia ( aiha ) . the association of acute pancreatitis in a cohort study of 551 sle patients included the withdrawal of a maintenance dose of steroids , the presence of seizures and of arthritis , and the authors of this study found no independent predictor of this complication . in yet another study , hypertriglyceridemia appeared to be a strong associate of pancreatitis in sle patients . authors in this study further observed that sle patients with psychosis and pleurisy were at increased risk for pancreatitis . the index case had a normal lipid profile and no cns or pleural involvement . the combination of sle and acute pancreatitis is a very serious complication , which could even be fatal , as reported by cairoli et al . . the spectrum of sle is not solely restricted to acute pancreatitis as the association of sle with chronic pancreatitis has been reported as well . in addition to her acute pancreatitis , the index case also developed features of acute autoimmune hemolytic anemia during her hospital stay . aiha may manifest itself in sle patients at the time of diagnosis , or within the first year following diagnosis . in this case , however , the index case presented with this complication 5 years after the diagnosis . aiha is often associated with thrombocytopenia , lupus nephritis and cns activity . to address the natural history and treatment response in aiha among sle patients , gomrad et al . the authors observed that aiha is a serious complication of sle , requiring urgent and appropriate management . in their study , patients responded to steroids in 96% of the cases and a recurrence rate of only 3 per 100 person - years was observed . furthermore , in the same study , 7 patients ( 27% ) experienced a relapse of aiha and required immunosupressants . based on their results , the authors recommended steroids as the first line of treatment , and advocated additional therapy with rituximab , danzol in refractory cases . our index case responded well to the steroid treatment , with no relapse over the two years of follow - up . massive hemolysis due to any reason has been found to be another cause of acute pancreatitis . retrospectively studied acute hemolysis due to different reasons in forty patients with drop of hematocrit greater than 12% over a period of 12 hours . pancreatitis was observed to be a complication of massive hemolysis with a prevalence of above 20% . the authors were of the opinion that the back pain often found in acute hemolysis may originate from the pancreas rather than the kidneys . experimental models have supported massive hemolysis as a cause of acute pancreatitis , and , in addition , histological changes following massive hemolysis have been observed in the pancreas in these experimental models . having said this , it is pertinent to mention here that the index case presented with acute pancreatitis and developed severe hemolysis during her stay in hospital , so there seems to be no temporal relation between the two ( acute pancreatitis with hemolysis ) . however , it is possible that low grade hemolysis taking place a few days before the manifestation of the acute pancreatitis actually precipitated the attack , as she had no other established risk factor of acute pancreatitis . however , it is certain that due to massive hemolysis during her hospital stay , her pancreatitis could have worsened had she not been managed in time .   in conclusion , it may be said that the present case brings to the fore the multiple complications of sle , a clinical scenario due to the generation of multiple autoantibodies directed towards the pancreas and the hemopoietic system . acute vasculitis with its varied clinical presentation is often the commonest cause of abdominal pain in sle , but acute pancreatitis and acute autoimmune hemolytic anemia , with its consequences , should be kept in mind in a given case of sle . further , this case emphasizes the need for close follow - up and proper health education in an sle patient in order to circumvent any complication .
a young female presented with acute abdominal pain of two days duration consistent with acute pancreatitis . during her stay in the hospital she had a sudden drop in hemoglobin to 6 g / dl without any overt blood loss . on evaluation , it was evident that she had acute pancreatitis , in addition to displaying features of autoimmune hemolytic anemia . 
 she had been a known case of systemic lupus erythematosus ( sle ) and had discontinued her treatment . 
 she was managed with methylprednisolone pulse therapy . 
 her clinical condition improved , and she has been regularly attending our clinic for the last 2 years . according to a literature search in medline , it would appear that this is the first report of a case in which sle with autoimmune hemolytic anemia has been associated with acute pancreatitis in a single case .