Having Flu No Clue: An Uncommon Cause of Pancreatitis

Abstract

Purpose: H1N1 (Swine Flu) has become a topic of much attention over the past two years. In April 2009, The World Health Organization designated the H1N1 outbreak a pandemic. Mild upper respiratory symptoms including cough, pharyngitis, rhinhorrhea, headache and fevers are commonly associated with H1N1 infection. Reports of rapidly progressive respiratory failure and death have been reported as well. Nausea, vomiting and diarrhea are frequent gastrointestinal symptoms occurring in 24% of patients. This is a case of a young woman with rapidly progressive respiratory failure due to H1N1 and clinical and laboratory evidence of acute pancreatitis with otherwise negative workup. Case Presentation: We are presenting a case of a 23 year old woman admitted to the ICU with H1N1 pneumonia. She denied any prior history of pancreatitis, use of drugs and autoimmune disorders. She drinks alcohol occasionally. Physical exam was significant for bilateral coarse rhonchi and minimal abdominal tenderness on deep palpation. Her amylase and lipase were 3 times the upper limit of normal. Her IgG4, ANA, serum calcium, liver enzymes and fasting triglycerides were within normal limits. Acute viral hepatitis panel was negative. CT abdomen showed grade B pancreatitis. No gallstones or biliary ductal dilation were seen on the abdominal ultrasound. Our patient made a complete recovery with oseltamivir. Discussion: Mumps, coxsackie, hepatitis B, cytomegalovirus, varicella-zoster, herpes simplex and HIV are some of the common causes of viral pancreatitis. Symptoms tend to be non-specific and the clinical course is often benign. The majority of cases resolve with conservative management. Clues to an infectious etiology lie in the characteristic syndrome caused by the infectious agent. Our patient is unique because she developed an acute pancreatitis along with a rapidly progressive respiratory failure secondary to H1N1 pneumonia. Her pancreatitis was mild, with minimal abdominal symptoms and moderate elevation of pancreatic enzymes. While ARDS can be a complication of a severe bout of pancreatitis, her history does not suggest that any abdominal symptoms preceded the onset of the respiratory symptoms. Conclusion: Besides pneumonia, H1N1 can cause mild pancreatitis. It could be diagnosed by elevated amylase and lipase with minimal radiologic findings.