Swine Flu: A Matter of the Pancreas Too

Abstract

Purpose: Introduction: Influenza A virus subtype H1N1 (Swine Flu) has become a topic of much attention over the past few months. In late April 2009, The World Health Organization labeled the H1N1 outbreak as a pandemic. Generally, symptoms associated with H1N1 are relatively mild, but cases of rapidly progressive respiratory failure and death have been reported. The main symptoms include fevers, cough, sore throat, headache and rhinorrhea. Common gastrointestinal manifestations may include nausea, vomiting and diarrhea. We report a case of a young woman with rapidly progressive respiratory failure due to H1N1 and clinical and laboratory evidence of acute pancreatitis with negative workup otherwise. Case presentation: Our patient is a 23-year-old woman who was admitted with H1N1 pneumonia and found to have elevated amylase and lipase. She denied any prior history of pancreatitis, use of drugs and autoimmune disorders. She drinks 1 glass of wine per week. Physical exam was significant for bilateral rhonchi and minimal abdominal tenderness. Amylase and lipase were 308 and 102u/L, respectively. Amylase isoenzymes were predominantly pancreatic in origin. Fasting triglycerides, serum calcium, liver enzymes, IgG subtype 4 and ANA were within normal limits. Acute viral hepatitis panel was negative. CT abdomen was negative for significant pancreatic inflammation. Abdominal ultrasound was negative for gallstones and biliary ductal dilation. Patient made a complete recovery with oseltamivir. Discussion: Viral etiologies of acute pancreatitis include mumps, coxsackie, hepatitis B, cytomegalovirus, varicella-zoster, herpes simplex and HIV. Non-specific symptoms are typical of viral pancreatitides 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. She underwent an extensive workup and no explanation for her pancreatitis was found. 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. We propose that due to all negative diagnostic workup for pancreatitis, H1N1 was the most likely etiology. A Medline search using the words H1N1/pancreatitis/swine flu was performed from 1946 through 2009 and yielded no results. This may indeed represent the first documented case of H1N1 pancreatitis.