Jamie Felzer, MD, MPH
Fellow
Mayo Clinic College of Medicine
Rochester, Minnesota
Disclosure information not submitted.
Jaime De La Fuente, MD
Fellow
Mayo Clinic College of Medicine, United States
Disclosure information not submitted.
Hilary DuBrock, MD
Assistant Professor of Medicine
Mayo Clinic College of Medicine, United States
Disclosure information not submitted.
Erin Demartino, MD
Assistant Professor of Medicine
Mayo Clinic College of Medicine, United States
Disclosure information not submitted.
Title: Early Plasmapheresis for Hypertriglyceridemia-Induced Severe Pancreatitis with Diabetic Ketoacidosis
Case Report Body:
Introduction: Hypertriglyceridemia-induced acute pancreatitis is a well-known but rare phenomenon. Very severe hypertriglyceridemia (HTG) with triglycerides greater than 2000 mg/dL is seen less than 0.05%.[1]
Description: A 45-year-old female with type 2 diabetes mellitus and hyperlipidemia with abdominal pain had diabetic ketoacidosis (DKA) and severe acute pancreatitis (AP) seen on cross-sectional imaging (lipase 1361 U/L (normal 13-60)).[2] Triglycerides were elevated at 3861 mg/dL. Aggressive crystalloid and insulin infusion as standard therapy decreased triglycerides to 2295 mg/dL in 14 hours.[3, 4] Due to worsening abdominal exam and progressive encephalopathy, one cycle of plasmapheresis was performed within 21 hours; triglycerides then dropped to 601 mg/dL. Patient left the intensive care unit in three days with resolution of systemic inflammatory response.
Discussion: The benefit of plasmapheresis in AP from HTG is unclear given the limited high-quality studies. The only prospective study failed to demonstrate a mortality benefit, which was partially attributed to delay in initiation of plasmapheresis.[5-7] Though it significantly lowers triglycerides, a follow up retrospective study failed to find a mortality difference comparing early to late plasmapheresis.[6] Multiple studies depicted, similar to our case, there is an accelerated decline in triglycerides following plasmapheresis compared to insulin therapy.[6] Randomized controlled trials are currently evaluating the difference between intensive insulin therapy, fluids alone and plasmapheresis.[8, 9]
The patient had discontinued medications and transitioned to Ayurvedic diet which likely contributed to her presentation of the confluence of untreated chronic medical conditions and highly morbid triad of DKA, HTG and AP.[10] There is correlation between poorly controlled blood sugars and higher triglycerides with more severe pancreatitis.[10] With the increase of obesity and diabetes worldwide, HTG AP could increase.
This case of DKA, HTG, and severe AP clinically progressed despite early initiation of insulin infusion, hence plasmapheresis was offered producing a rapid resolution of symptoms and normalization of laboratory anomalies. The role of plasmapheresis for this life-threatening syndrome will be better elucidated in forthcoming clinical trials.