What could be causing vomiting and nausea upon waking in an 11-year-old patient with a history of Systemic Lupus Erythematosus (SLE)?

Morning Nausea and Vomiting in an 11-Year-Old with SLE

In an 11-year-old with SLE presenting with morning nausea and vomiting, you must immediately rule out neuropsychiatric lupus (NPSLE) manifestations—particularly increased intracranial pressure or acute confusional state—while simultaneously evaluating for cyclic vomiting syndrome, gastroparesis, and medication-related causes.

Immediate Life-Threatening Considerations

Neuropsychiatric SLE (NPSLE)

• Morning vomiting is a red flag for increased intracranial pressure from CNS lupus involvement, which can present with headache pattern changes, visual disturbances, or altered mental status 1
• Acute confusional state (ACS) in SLE requires urgent evaluation with CSF examination to exclude CNS infection and brain imaging if focal neurological signs, fever, or no obvious cause is identified 2
• Brain MRI is indicated urgently if any neurological signs accompany the vomiting, as cerebral atrophy (40%) and white matter lesions (50-55%) are common in NPSLE 2

Critical Initial Assessment

• Perform immediate neurological examination looking for focal signs, altered consciousness, meningismus, or papilledema 2
• Check for fever, as this mandates CSF examination to exclude CNS infection in immunosuppressed SLE patients 2
• Assess for signs of acute lupus flare with concurrent systemic symptoms 2

Differential Diagnosis Framework

Cyclic Vomiting Syndrome (CVS)

CVS should be strongly suspected if the patient has stereotypical episodes of acute-onset vomiting lasting <7 days, with at least 3 discrete episodes in the past year separated by ≥1 week of baseline health 3, 4

Key diagnostic features to elicit:

• Prodromal symptoms including impending sense of doom, panic, fatigue, mental fog, restlessness, anxiety, headache, bowel urgency, diaphoresis, or flushing—present in 65% of CVS patients 3, 4
• Episodes occurring predominantly in early morning hours 3
• Personal or family history of migraine (present in 20-30% of CVS patients) 3, 4
• Screen for cannabis use (>4 times weekly for >1 year suggests cannabinoid hyperemesis syndrome instead) 3, 4

Gastroparesis

• Post-prandial symptom exacerbation with early satiety suggests gastroparesis 4
• Gastric emptying scintigraphy (2-4 hour study) is required for diagnosis if suspected 2, 4
• Post-viral gastroparesis can occur in pediatric patients 1

Medication-Related Causes

• Corticosteroid-induced psychiatric manifestations occur in 10% of patients on prednisone ≥1 mg/kg, primarily as mood disorder (93%) rather than psychosis 2
• Review all immunosuppressive medications for nausea as adverse effect 5, 6
• Opioids cause nausea in 10-50% of patients 1

Metabolic and Endocrine Causes

• Check for hypercalcemia, hypothyroidism, and adrenal insufficiency 4, 7
• Addison's crisis can present with intractable nausea and vomiting in patients with autoimmune conditions 7

Diagnostic Algorithm

Step 1: Emergency Exclusion (Immediate)

• Neurological examination for signs of increased intracranial pressure or ACS 2, 1
• If any neurological signs present: obtain urgent brain MRI and consider CSF examination 2
• Check vital signs for fever (mandates infection workup in immunosuppressed patient) 2

Step 2: Laboratory Evaluation

• Complete blood count, serum electrolytes, glucose, liver function tests, lipase 4
• Check for hypokalemia, hypochloremia, and metabolic alkalosis from prolonged vomiting 4
• Assess for hypercalcemia, thyroid function, and cortisol if clinically indicated 4, 7
• Evaluate SLE disease activity markers 2

Step 3: Pattern Recognition

• Document timing, duration, and frequency of vomiting episodes 3, 4
• Identify prodromal symptoms suggesting CVS 3, 4
• Assess relationship to meals (gastroparesis vs. CVS) 2, 4
• Screen for cannabis use patterns 3, 4

Step 4: Structural Evaluation (If No Emergency Findings)

• Perform upper endoscopy if symptoms persist >7 days to exclude mechanical obstruction, peptic ulcer disease, or malignancy 1, 4
• Obtain gastric emptying scintigraphy if gastroparesis suspected based on post-prandial symptoms 2, 4

Step 5: Psychiatric Comorbidity Assessment

• Screen for anxiety, depression, and panic disorder—present in 50-60% of CVS patients 3, 4
• Treating underlying anxiety can decrease CVS episode frequency 3, 4

Management Approach

If NPSLE Suspected

• Combination of glucocorticoids with immunosuppressive agents (response rates up to 70% for ACS) 2
• Pulse intravenous methylprednisolone combined with intravenous cyclophosphamide for severe manifestations 2
• Address and correct any underlying precipitating conditions, especially infections 2

If CVS Diagnosed

For Moderate-Severe CVS (≥4 episodes/year lasting >2 days requiring ED visits):

• Prophylactic therapy: Amitriptyline 25 mg at bedtime, titrating to 75-150 mg nightly (1-1.5 mg/kg) with baseline ECG monitoring for QTc prolongation 2, 3
• Abortive therapy: Educate patient to recognize prodromal symptoms and immediately take sumatriptan 20 mg intranasal spray plus ondansetron 8 mg sublingual 3, 4
• Sumatriptan can be repeated once after 2 hours (maximum 2 doses per 24 hours) 3

For Mild CVS (<4 episodes/year lasting <2 days):

• Abortive therapy only with sumatriptan plus ondansetron 3

Lifestyle modifications for all CVS patients:

• Regular sleep schedule avoiding sleep deprivation 3, 4
• Avoid prolonged fasting 3, 4
• Stress management techniques 3, 4
• Identify and avoid individual triggers 3, 4

If Gastroparesis Confirmed

• Patient education and dietary counseling with small, frequent meals 8
• Gastrokinetic drugs as indicated 8
• Address concurrent SLE activity with glucocorticoids and/or immunosuppressive therapy 2

Critical Pitfalls to Avoid

1. Missing the neurological emergency: Morning vomiting in SLE can be the presenting sign of increased intracranial pressure or CNS infection—always perform thorough neurological examination first 2, 1

2. Overlooking medication effects: Corticosteroids and immunosuppressants commonly cause nausea, and corticosteroid-induced psychiatric manifestations occur in 10% of patients on high-dose therapy 2, 5

3. Missing the prodromal window in CVS: The probability of successfully aborting a CVS episode is highest when medications are taken immediately at onset of prodromal symptoms 3

4. Misdiagnosing cannabinoid hyperemesis syndrome as CVS: Cannabis use >4 times weekly for >1 year requires 6 months of cessation to differentiate 3, 4

5. Underestimating psychiatric comorbidity: Anxiety and depression are present in 50-60% of CVS patients and treating these can decrease episode frequency 3, 4

6. Delaying infection workup: SLE patients have 13 times higher incidence of invasive pneumococcal infection and are at high risk for serious infections requiring aggressive evaluation 2