Cerebral infarction leading to hemiplegia: A rare complication of acute pancreatitis
A 48-year-old male, heavy alcohol consumer for the prior 6 years, presented with complaints of severe abdominal pain, vomiting and constipation for 3 days. There was no history of diabetes mellitus, hypertension, smoking, and previous abdominal pain. On admission to our hospital (on day 4 of illness), he was hemodynamically stable, had abdominal distention with diffuse tenderness and absent bowel sounds. Laboratory work up on day 4 revealed serum amylase: 898 U/l, lipase: 968 U/l, glucose: 116 mg/dl, Na+: 132 mEq/l, K+: 3.6 mEq/l, creatinine: 1.9 mg%, calcium: 8.6 mg/dl, bilirubin: 1.4 mg/dl, aspartate transaminase/alanine transaminase: 74/28 IU/l, alkaline phosphatase: 181 IU/l, serum proteins/albumin: 7.1/2.9 g/dl, serum cholesterol: 124 mg/dl, triglycerides: 130 mg/dl, Hb: 8.4 g/dl, leucocytes: 15,400/μl, platelets: 98,000/μl, prothrombin time: 18 s, activated partial thromboplastin time: 40 s. Computed tomography (CT) of abdomen [] carried out with intravenous contrast on day 4 revealed enlarged, diffusely enhancing pancreas, multiple peripancreatic fluid collections and bilateral pleural effusions, confirming grade E AP (CT severity index = 4). He was kept nil per orally. Continuous nasogastric aspiration, intravenous fluids, stress ulcer prophylaxis and subcutaneous unfractionated heparin 5000 units twice/day for venous thromboprophylaxis were started. On day 5, he developed right sided hemiplegia. CT of brain revealed large left MCA territory infarct [Figures and ]. Electrocardiogram (ECG) and echocardiography of the heart were normal. Work up for hyperhomocysteinemia, protein C and S deficiency, factor V Leiden, antithrombin III deficiency and antiphospholipid antibody syndrome was negative. Patient developed high grade fever and progressive acute renal failure from day 6. He was started on piperacillin + tazobactam and metronidazole. He was intubated on day 8 for progressive respiratory distress and hypoxia and was shifted to intensive care unit for mechanical ventilation. On day 9, he developed shock and was discharged against medical advice upon insistence of his relatives.