Missing the Forest for the Trees

A multisystem disease such as systemic lupus erythematosus (SLE) requires a comprehensive history, physical exam, and review of systems to establish a correct diagnosis. The chapter discusses a case study, where an extensive evaluation was necessary to exclude other etiologies of abdominal pain and systemic illness, particularly as infectious and neoplastic conditions occur far more often than lupus enteritis in the general population. The cohesively abnormal "forest" may have been obscured by erratically abnormal individual "trees". Abdominal pain occurs in up to 40% of patients with SLE, but mesenteric vasculitis is the cause in fewer than 1%. Neutropenia is often a result of myelotoxicity from immunosuppressive therapy, rather than SLE itself. Enteric vasculitis due to SLE is challenging to diagnose. Serologic tests and routine imaging results are nonspecific, and angiography may be normal. Diagnosis relies on searching for other clues to systemic involvement by SLE and reasonably excluding alternative disorders.