Atypical presentation of painless acute pancreatitis: A case report

Painless acute pancreatitis (PAP) is a slowly progressive disease that involves inflammation, scarring, and thickening of pancreatic cells, which can happen due to either alcohol, idiopathic, or genetic. Clinicians usually miss PAP due to lack of pain and additional symptoms of hypotension and fever can lead to an infectious work-up instead. In this case report, we discuss the importance of the rapid discovery of this condition to prevent devastating complications like diabetes, necrotizing pancreatitis, or even death.

A 47-years old male with past medical history of hypotension and alcohol abuse presented for loss of consciousness. Patient was found with pinpoint pupils, hypoglycemia, and hypotensive. He received Narcan, dextrose, and IV fluids and became responsive. In the emergency department, the patient was hypotensive and the physical exam was only significant for diaphoresis. Patient denied abdominal or radiating pain. Labs significant for elevated lipase, metabolic acidosis, and hyponatremia with imaging positive for AP without chronic inflammation. Based on imaging, lipase and absence of pain, PAP was diagnosed. Patient had multiple episodes of hypoglycemia and remained hypotensive requiring pressor support and intubation. After intubation, he had pulseless electrical activity cardiac arrest. Return of spontaneous circulation achieved but the patient had worsening acidosis, acute kidney injury, liver injury, and bandemia. Empiric antibiotics started, dexamethasone, and maxed on five pressors and transferred to the medical intensive care unit for management of severe AP (SAP).

This case report featured PAP without chronic inflammation which is an even rarer disease than PAP which progressed to SAP.