A Rare Culprit in Pancreatitis

Abstract

The most common etiologies of pancreatitis include alcohol abuse, biliary obstruction, and hypertriglyceridemia. Drug-induced pancreatitis is much rarer, accounting for only 0.3-1.4% of cases. A 19-year-old male with past medical history of ulcerative colitis and morbid obesity presented with a 2-day history of abdominal pain and diarrhea. The pain was rated 8 out of 10, epigastric and nonradiating. He denied any abdominal trauma. He did not have any nausea, vomiting, fever, chills, or recent weight loss. He also denied any history of alcohol or tobacco use. A week earlier, he was treated at another facility for an ulcerative colitis flare and was found to have Clostridium difficle colitis. He was discharged on a 14-day course of metronidazole and had completed 7 days at the time of presentation. His other home medications included budesonide and mesalamine. Of note, he had another episode of pancreatitis 8 months earlier; no etiology was identified. He was, however, taking metronidazole at the time of symptom onset and all symptoms resolved after discontinuation. Physical exam on this admission showed mild tachycardia and marked obesity. Abdomianl exam was unremarkable except for moderate epigastric tenderness. Laboratory testing revealed a lipase level of 3151 U/L. Liver panel was unremarkable, ethanol level was negative, triglyceride level was 91 mg/dL, and calcium was 9.2 mg/dL. ESR and CRP were both elevated (26 mm/hr and 12.9 mg/dL, respectively). IgG4 and ANA levels were unremarkable. Abdominal CT showed mild pancreatic edema and swelling (Figure 1). The patient was admitted for acute pancreatitis and was treated with pain control, bowel rest, and IV hydration. Metronidazole was switched to vancomycin for C. diff colitis. The patient improved clinically and was discharged on vancomycin. At a 1-week follow-up, his abdominal pain had completely resolved.Figure 1Pancreatitis is an extremely rare put potentially serious complication of metronidazole use, with only nine cases reported in the English literature. As it is an uncommon cause of pancreatitis, it may often be overlooked. If metronidazole is suspected as the causative agent, it should be discontinued and rechallenge should be avoided.