Fellow Physician University of Iowa Hospital Clinics Pulmonary and Critical Care Medicine, United States
Introduction: Emphysematous pancreatitis is an unusual and life-threatening complication of necrotizing pancreatitis, affecting 33% of necrotizing pancreatitis cases and 3.3-5% of all pancreatitis cases. It is characterized by the presence of gas within the necrotic pancreatic bed due to superimposed bacterial or fungal infections. It is the most serious complication of necrotizing pancreatitis and failure to rapidly identify or adequately treat it can be fatal, with mortality rates ranging from 40% to 70%.
Description: A 65-year-old male with a medical history of heart failure with reduced ejection fraction and type II diabetes mellitus presented with worsening shortness of breath, nausea, and diarrhea. He was found to have emphysematous pancreatitis with Klebsiella bacteremia, later complicated by fungemia. He had refractory fevers despite being on broad-spectrum antimicrobials and antifungals. He subsequently developed acute hypoxic respiratory failure requiring intubation, persistent hypotension requiring vasopressors, and acute renal failure requiring continuous renal replacement therapy. He was not considered a surgical candidate due to his hemodynamic instability and multi-organ failure. Unfortunately, despite aggressive medical therapy, he expired.
Discussion: Although most pancreatitis cases are due to inflammation, superimposed infections can lead to emphysematous pancreatitis and subsequent mortality if not promptly identified and treated. This is usually caused by gas-forming bacteria, mostly gram-negative, including Escherichia coli, Klebsiella sp., Pseudomonas sp., Enterobacter, and Clostridium perfringens. Fungal infection can also happen, with Candida sp. being the most common organism. Given its high mortality rate, emphysematous pancreatitis should be considered in all pancreatitis cases. Patients with emphysematous pancreatitis should be treated with broad-spectrum antimicrobials and especially surgical source control early if indicated to prevent negative outcome. Our patient, unfortunately, was not able to get surgical intervention due to his hemodynamic instability. Early diagnosis and aggressive management are critical to improve patient outcomes.
