PC3061: Cause or Effect? a Devastating Case of Hyperglycemic Crisis with Post-mortem Findings of Hemorrhagic Pancreatitis and Arrhythmogenic Right Ventricular Cardiomyopathy

Introduction: Diagnosing pancreatitis while in a hyperglycemic crisis is diagnostically challenging as these patients often present with non-specific enzyme elevation without evidence of pancreatitis on imaging studies. It is ultimately unclear the etiology of pancreatitis in hyperglycemic crisis however based on current data its incidence is about 2% of pediatric patients who present in DKA. This begs the question of whether severe pancreatitis was the inciting event to this patient’s hyperglycemic crisis or rather a subsequent complication.

Case Description: We present a 16-year-old male with a history of morbid obesity admitted with altered mental status. Prior work-up for light-headedness same week included normal ECG and blood glucose and a Hgba1c of 5.7 nine months prior to admission. Initial lab work revealed capillary pH 6.92 and pCO2 32.5; glucose 1762 mg/dL, HCO3 < 5, Cr 3.62, and serum OSM 424. Pancreatic enzymes were not obtained. In the ED, fluid resuscitation was initiated, mannitol was given, and Head CT was negative for cerebral edema. In the PICU, treatment for DKA/HHS included rehydration with double-bag IVF and continuous insulin infusion. On hospital day 2, after a brief period of mild improvement in mental status with decreasing serum OSM and glucose, he rapidly decompensated following an aspiration event with black-tarry emesis leading to cardiac arrest. ROSC was achieved after 28 minutes of resuscitation effort. Despite maximal vasopressor support, placement on VA ECMO and placement of a temporary catheter based LVAD, the patient’s shock proved irreversible and life-saving measures were withdrawn. Autopsy demonstrated diffuse multi-organ failure with acute-on-chronic hemorrhagic necrosis of the pancreas. An incidental finding included left ventricular hypertrophy with fibro-fatty infiltration in the heart consistent with a diagnosis of Arrythmogenic Right Ventricular Cardiomyopathy.

Discussion: Ultimately, the etiology of our patient’s hemorrhagic pancreatitis is unknown. Due to evidence of chronicity on autopsy, we hypothesize that his presentation in DKA/HHS was likely a result of the hemorrhage rather than a consequence of his hyperglycemic crisis. It is also unclear if the incidental finding of ARVC was a contributing factor, but it would stand to reason that a cardio-ischemic event may have provided the insult to the pancreas.

Conclusion: We assert that clinicians should consider a screening lipase/amylase and Abdominal CT while considering other rare causes in those presenting with new onset severe hyperglycemic crisis.