Unusual clinical course
Richard H. Zou, Joseph S. Bednash
Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Med Sci Case Rep 2018; 5:6-9
Conferring a high risk of mortality, severe acute pancreatitis is often complicated by a robust inflammatory response and multi-organ failure. Non-traumatic rhabdomyolysis is another life-threatening medical condition associated with elevated creatine phosphokinase (CPK) and acute kidney injury (AKI). While associations between mild-to-moderate rhabdomyolysis after acute pancreatitis have been described, we report a case of severe rhabdomyolysis complicated by AKI requiring renal replacement therapy (RRT) in a patient with severe acute pancreatitis and hyperthermia.
CASE REPORT: A 45-year-old male presented with a 1-day history of epigastric pain. The physical exam was significant for mild abdominal distension without rebound or guarding. Initial laboratory resting revealed white blood cell count (WBC) 24.7 with 83% neutrophils, amylase 1162 U/L, lipase 7846 U/L, corrected calcium 9.4 mg/dL, triglyceride (TG) 158 mg/dL, and CPK 3135 IU/L. Computed tomography (CT) revealed extensive peripancreatic fluid and fat stranding. He quickly developed acute hypoxemic respiratory failure requiring intubation and mechanical ventilation. He was started on aggressive fluid resuscitation with antibiotic therapy after he became persistently febrile up to 41.1°C. Repeat imaging was remarkable for severe pancreatic necrosis. CPK increased to a peak level of 90 627 IU/L and creatinine worsened to a peak level of 6.9 mg/dL. There was no evidence of compartment syndrome. The patient was started on continuous veno-venous hemodialysis (CVVHD) with subsequent transition to intermittent dialysis with gradual recovery of renal function. He was eventually extubated and discharged home in stable condition.
CONCLUSIONS: There exists a potential association between acute pancreatitis-induced systemic inflammation with persistent hyperthermia and severe non-traumatic rhabdomyolysis. Medical management should focus on supportive care and reversal of underlying etiologies.
Keywords: acute kidney injury, Fever, Pancreatitis, Acute Necrotizing, rhabdomyolysis