Medical Mystery...can anyone help solve!

[JJRBuckeyeRN]

I have been taking care of a male pt for the last couple days that seems to be a medical mystery....

36 yo male

PMHx- unidentified connective tissue disorder, G-5 deficiency (which I believe causes anemia), 100lbs wt loss in the last 10-12 months.

Several cases of pneumonia in the last 6 months.

Came to us with a septic picture. Febrile, tachy, hypotensive.

Echo showed an EF of 10-20%.

They think that he has an autoimmune disorder and are working him up accordingly...we are still waiting for most of these labs to come back.

The question is.. his Amylase and Lipase continue to climb. They are both over 1000 at this point, and his CK continues to climb as well. The MDs seem to believe that the pancreatitis is somehow related to an autoimmune disorder.

Have any of you seen this kind of picture before in pts you have treated? Any idea what autoimmune disorder could be causing the pancreatitis?

Side note----he had a full body scan about a week ago that did not show anything. I think he was going to go back today for another CT to see if there was anything that would help us understand why his pancreatic enzymes are climbing.

Thanks for your help!

[athena55, BSN, RN]

Well, some causes of acute pancreatitis are alcohol use, gallbladder or biliary disease like gallstones, certain meds (think thiazide diuretics), pancreatic surgery, traumatic injury, certain viral infections like mumps...

What exactly causes pancreatitis is still not known: Some think that the enzymes normally excreted by the pancreas in their inactive form somehow become activated inside the pancreas and start the process of auto digestion, which can start SIRS and lead to ascites and, if not caught, abdominal compartment syndrome (ACS)

What was the patients trypsin level?

As you know, lipase is more sensitive and specific when detecting pancreatitis, especially alcoholic pancreatitis. Non-pancreatic conditions can cause an increase in amylase.

I realize it has been 7 days since you last wrote. How is this patient doing?

athena

[dopaminequeenRN]

Wow! This sounds interesting....Have you gotten most of the labs back and if so, did they point to a more specific diagnosis? Athena55 sounds like she knows her stuff! I wish I had something to contribute here, but I'm flabbergasted. Please keep us posted!

[nursejill155]

I'm not very good with autoimmune stuff there is A LOT of it and it usually presents in an akward way. It may be related and maybe not...is he a drinker? I'm interested keep us posted

[lamabamachinchang]

What's his temperature? How difficult is it to treat? Does 650 mg acetominophen reduce his temp, or is it more persistent? I can't tell you how many times I've run into febrile patients where healthcare personnel just let it slide, including low-grade febrile patients (99-100) until the patient developed complications.

I'd say put the patient on a cooling blanket and keep his temp subnormal, say, around 97 oral/rectal. Also support with plenty of fluids, and make sure the patient has regular BM, preferably with lactulose PO.

Good luck getting the doctors to understand.

[africanaloe]

We had such a case and lo and behold after checking for all sorts of diseases the dude had advanced syphllis..lol...

[elizadream]

We had such a case and lo and behold after checking for all sorts of diseases the dude had advanced syphllis..lol...

You may be right! There was a case in my own ICU where an 81 yr old man , after exhausive tests, was HIV +

[globalRN]

is it an autoimmune hepatitis? vasculitis

is it a drug related reaction?

Never heard of g-5 but have heard of G6PD

does he have hypogammaglobulinemia?

and yes, test for infections: all the hepatitis viruses and HIV

Infectious disease consult?

GI consult

[1blueangel2]

AIDS, sarcoidosis, CA, leukemia--sounds like more than one diagnosis will be confirmed though. definitely MODS. very well could have an undiagnosed pre-existing condition before the sepsis set in. keep us updated.