key: cord-0729611-egujq0ob
authors: Galarza-Delgado, Dionicio Ángel; Flores-Alvarado, Diana Elsa; Compeán-Villegas, Jesús Eduardo
title: Superior mesenteric artery syndrome in a patient with rheumatoid arthritis and rheumatoid cachexia during the COVID-19 pandemic
date: 2021-01-11
journal: Clin Rheumatol
DOI: 10.1007/s10067-020-05570-x
sha: 475f5e31b885946624258a1a5274bb644eee9aac
doc_id: 729611
cord_uid: egujq0ob

nan

We report the case of a 30-year-old Mexican woman who presented to the emergency department due to intense abdominal pain. She had a 5-year prior diagnosis of rheumatoid arthritis (RA). On examination she appeared pale and cachectic. Her body mass index was 17.5 kg/m 2 . Renal and liver function was normal. Rheumatoid factor isotype IgM 73 U/mL (< 20) and anti-CCP antibodies 15 U/mL (< 5) were positive. Computed tomography scan revealed a decrease in the aortomesenteric distance (AMD) with an anteroposterior diameter of up to 6 mm leading to a significant decrease in the third duodenal portion caliber. In sagittal section, a decreased of the aortomesenteric angle (AMA) of 14°was measured (Fig. 1) . Infections, neoplasms, endocrine disorders, malabsorption, and intestinal ischemia were ruled out.

As her SARS-CoV-2 PCR test was positive, she was transferred to the COVID-19 hospital area causing a delay in her therapeutic management. She was treated with total parenteral nutrition for a month until she was able to be fed by mouth.

Superior mesenteric artery (SMA) syndrome is an uncommon disorder in which acute angulation of the SMA causes compression of the third portion of the duodenum against the aorta leading to obstruction. Loss of retroperitoneal fatty tissue is believed to be the etiologic factor [1] .

Normally, the AMA is between 38 and 56°, but when it decreases to 6-22°, extrinsic compression of the duodenum can occur. The AMD with a normal interval of 10-28 mm, can decrease to 2-8 mm in SMA syndrome. As the computed tomography allows for evaluation of these parameters and exclude other diagnosis, it is a valuable imaging modality [2].

Patients with RA are at risk of rheumatoid cachexia, a serious consequence of refractory or long-standing disease. Unlike classic cachexia, an excess of proinflammatory cytokines is the central feature, which leads to muscle proteolysis and anorexia, perpetuating the loss of body cell mass [3] , and finally in the SMA syndrome. According to case report recommendations, the initial management of the patient was conservative [4] . Those strategies include adequate fluid resuscitation, positioning to increase the AMD, gastric decompression, postpyloric feeding when possible followed by oral diet as tolerated [5] . Although the information on rheumatological diseases and SMA syndrome is scarce, there is sufficient theoretical to support its consideration. This case leads to reflection on the importance of the nutritional assessment of patients with rheumatological diseases and highlights the impact that the pandemic has had so far on the diagnostic and therapeutic approach of patients with systemic rheumatic diseases and their associated complications.

Contributors DAGD, DEFA, and JECV contributed equally to the manuscript. All authors critically revised and approved the final version of the manuscript.

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