A Common Disease with Uncommon Association-A case of fatal acute pancreatitis with hyperparathyroidism

Presented By Dr. Shakila Parveen,Junior Consultant, Radiology and Imaging, United Hospital

A 51 year old lady, was admitted into GHDU of United Hospital through ER on 5th March, 2013 with the c/o severe abdominal pain and vomiting  several times for 1 day and constipation for 2 days. Her history of past illness was significant for hypertension and diabetes.
 
On admission, the patient was dehydrated and drowsy, pulse- 80/m, BP- 80/60 mm of Hg. On per abdominal examination, she had moderate tenderness over right hypochondriac and epigastric region, bowel sound was sluggish and shifting dullness was positive. She was diagnosed to have Acute Pancreatitis with DM and HTN. In GHDU, treatment started empirically with I/V Meropenem and all antihypertensive drugs were put on hold.

Investigations revealed, total count of WBC 16,800/ mm3, Serum Amylase  > 1500 U/L, Serum  Lipase  > 4000 U/L, Serum potassium- 6.2 mmol/L, Serum calcium- 2.98 mmol/L, Urine R/E- pus cell > 100 and 
Sugar- ++++. Ultrasonography of W/A suggested Acute Pancreatitis. On the 3rd day of admission she developed electrolyte imbalance, urinary sepsis, AKI and was shifted to GICU. Follow up CT scan revealed Necrotizing Pancreatitis with loculated peri-pancreatic collection.

Culture of percutaneous drainage of peri pancreatic collection showed growth of gram negative bacilli. Later on, the patient was treated by necrosectomy as well as cholecystectomy. As the patient had elevated serum calcium ( > 3 mmol/L) and serum PTH level was 223.2 pg/ ml, USG of neck showed a small mixed echogenic mass in right lower parathyroid region. FNAC report of the nodule was parathyroid adenoma.
In GICU the patient developed different hospital acquired infections.

In spite of the effort of physicians and the modern treatment she received, she succumbed to her illness. The lady had necrotizing pancreatitis, stemmed from parathyroid adenoma. Pancreatitis is uncommonly linked to hyper- parathyroidism, but it is often severe when the two are associated. The mortality rate of severe infected necrotizing pancreatitis is 25%-70%.