When biochemistry fails: extreme lipemia masking hypertriglyceridemia-induced acute pancreatitis treated with insulin

A 30-year-old previously healthy male presented to the emergency department with malaise, nausea, and abdominal pain. He was alert and oriented but in significant discomfort. Examination revealed abdominal guarding without peritoneal signs, and other systemic examinations were unremarkable. Initial laboratory evaluation was severely limited by extreme lipemia, preventing biochemical analysis and resulting in diagnostic uncertainty. Complete blood count showed leukocytosis, thrombocytosis, and hemoconcentration (hemoglobin 24.6 g/dL [SI: 246 g/L]; reference range 12.0-17.0 g/dL [SI: 120-170 g/L]). Acute pancreatitis was suspected, but abdominal computed tomography showed no definitive pancreatic abnormalities. The patient was admitted to the intensive care unit due to diagnostic uncertainty and concern for severe metabolic derangement. In the absence of confirmatory laboratory data, empiric insulin infusion with dextrose supplementation and hourly glucose monitoring was initiated to treat presumed hypertriglyceridemia via lipoprotein lipase activation. On day 3, biochemical testing confirmed hypertriglyceridemia with triglycerides of 6300 mg/dL (SI: 71.2 mmol/L) (reference range <150 mg/dL, [SI: <1.7 mmol/L]). Triglycerides decreased to 243 mg/dL (SI: 2.74 mmol/L) by day 8. Follow-up imaging demonstrated a 5 cm pancreatic pseudocyst managed conservatively. The patient was discharged on lipid-lowering therapy and dietary modification. At 6-week follow-up, the pseudocyst had regressed and he remained asymptomatic.