Lupus-Associated Acute Pancreatitis: A Rare Manifestation of Disease Activity

Acute pancreatitis affects fewer than 1% of patients with systemic lupus erythematosus (SLE) and usually occurs during active disease. Azathioprine and corticosteroids, both used to treat SLE, can also cause pancreatitis, so the origin of an episode often remains uncertain. A 41-year-old woman with a two-year history of SLE presented in August 2024 with four days of epigastric pain, diarrhea, and migratory polyarthralgia. She had stopped azathioprine on her own and took hydroxychloroquine and prednisone irregularly. Lipase was 17 times the upper limit of normal, and contrast-enhanced computed tomography showed interstitial oedematous pancreatitis with a CT Severity Index of 2. The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI-2K) score was 20, with low complement, positive anti-dsDNA, and proteinuria at 0.81 g/L. Gallstones, alcohol, hypertriglyceridemia, hypercalcemia, and drug toxicity were excluded. Pain resolved within 48 hours of three pulses of intravenous methylprednisolone, and CRP fell from 49 to 15 mg/L at one month. Azathioprine had been discontinued before the episode and was subsequently reintroduced without recurrence over 18 months, arguing against drug-induced pancreatitis. In most reported cases, the suspected agent is continued throughout, so this distinction remains unresolved. The exposure sequence observed here supports attributing the episode to lupus activity and favours intensification of immunosuppression over its withdrawal when SLE is active, and no alternative cause is identified.