Age: 68.0
Sex: M
Vaccine: HEPA
Symptoms: Gastric varices, Hepatic steatosis, Hepatitis A, Hepatitis A antibody positive, High density lipoprotein decreased
Clinical narrative: Nov 2024, family vacationed in another country. Dec 2024, the patient's wife and son contracted hepatitis A, and recovering. Patient received a single dose PEP hep A vaccine (12/14/24), no IG 1/10-1/16/25:  clinic visit; patient developed chills, myalgias, abd pain; diagnosed with a respiratory infection (antibiotics), sent home but not improved.  1/21/25: ER visit ICU admission: severe upper abdominal pain, radiating to the back, nausea, vomiting, and occasional dry heaves. No fever but chills.  Oral intake became nil, and he reported a 30lbs weight loss per 3-4 weeks; temp 36.4 °C, blood pressure 134/109, heart rate 78, respiratory rate 20. Lipase 730 (1/21/2025). AST938, ALT3845, AP443, bili6.1 MRCP: pancreatitis   Following his respiratory illness, patient developed severe upper abdominal pain that radiated to the back, nausea, vomiting, and occasional dry heaves.  No objective fever; he had chills.  Oral intake became nil, and he reported a 30 pound weight loss in the weeks prior to admission.  Upon arrival to ED (1/21/2025): temperature 36.4 °C, blood pressure 134/109, heart rate 78, respiratory rate 20.  Lipase 730 (1/21/2025).  AST 938, ALT 3845, alkaline phosphatase 443, bilirubin 6.1.  MRCP (1/21/2025): hepatic steatosis; peripancreatic edema localized to the pancreatic head consistent with pancreatitis; normal gallbladder without cholelithiasis.  No pancreatic divisum. Patient was admitted for acute pancreatitis. Hospital course: Triglyceride 594 (1/21/2025).  Insulin clamp 10 units/hour administered (1/21/2025 - 1/22/2025). 1/24/2025: CT abdomen/pelvis (1/24/2025): diffuse fatty infiltration of the liver; diffuse pancreatic edema with early pseudocyst formation in the tail of the pancreas; extensive fluid extending into the paracolic gutter and left side of the pelvis; nonocclusive splenic vein thrombosis. 1/26/2025: Overnight, he had a nosebleed with passage of clot; this resolved. Ultrasound abdomen (1/26/2025): no ascites. 1/28/2025: Patient tolerated a very low-fat diet. 1/29/2025: Scrotum and penis swollen. Albumin 1.8; albumin 50 g IVPB. Furosemide 20 mg IV; KCl 40 mEq p.o.  1/30/2025: Breathing improved. CT abdomen/pelvis (1/30/2025): small area of necrosis in the pancreatic tail similar; new/more conspicuous small area of necrosis in the uncinate process; moderate peripancreatic stranding; no organized fluid collection; no ascites. Albumin 2.3; albumin 50 g IVPB. Furosemide 20 mg IV; KCl 40 mEq p.o.  1/31/2025: Patient had a copious urine output, and his abdomen was less distended.  Breathing improved.  He has not used his PCA for several hours.  2/1/2025: Patient said that he feels like he is getting better and stronger for the first time. Patient developed patchy erythematous rash on his buttocks consistent with allergic reaction. Patient went most of the day without using his PCA pump  2/2/2025: Patient having copious diarrhea.  Stool pathogen panel (2/2/2025) no pathogens detected.  2/3/2025: PCA discontinued.  Heparin drip transition to apixaban 10 mg twice daily. Discharge diagnoses: 1.  Acute, necrotizing pancreatitis.  Protonix 40 mg IV twice daily.  Fentanyl PCA (1/21/2025).       A. CT abdomen/pelvis (1/24/2025): diffuse fatty infiltration of the liver; diffuse pancreatic edema with early pseudocyst formation in the tail of the pancreas; extensive fluid extending into the paracolic gutter and left side of the pelvis; nonocclusive splenic vein thrombosis.       B. CT abdomen/pelvis (1/30/2025): similar, small area of necrosis in the pancreatic tail; new/more conspicuous small area of necrosis in the uncinate process; moderate peripancreatic stranding; no organized fluid collection; no ascites; proximal splenic vein occlusion with upper abdominal gastric varices.       C. IgG1 1690; IgG4 20.5 (1/27/2025).  IgG4 is not elevated. 2.  Sepsis due to infected pancreatic necrosis.  ersistently tachycardic.  WBC progressively rose to 20.88 with 10% bands (1/23/25).  Procalcitonin 11.2 (1/24/25). Meropenem 2 g every 8 hours x 30 doses (1/23/20252/1/2025). 3.  Splenic vein thrombosis due to pancreatitis.  Initially, systemic anticoagulation deferred; high risk of bleeds.  As of 1/30/2025, has gastric varices       A. Weight-based heparin protocol (1/31/20252/3/2025).       B. Apixaban 10 mg twice daily for 5 days (2/3/2025 - 2/7/2025).       C. Apixaban 5 mg twice daily for 3 months. 4.  Acute hepatitis A.  Hepatitis A IgM reactive (1/21/2025) and transaminase values are consistent with acute infection. Not thought as HAV vaccine consequence 5.  Acute hypoxemic respiratory failure (1/24/2025).       A. Chest x-ray (1/24/2025) bibasilar atelectasis; no evidence of heart failure.  Incentive spirometry.       B. Subsequent volume overload (1/29/2025).            I. Furosemide 20 mg IV (1/29/2025); KCl 40 mEq p.o. (1/29/2025); albumin 50 g IV (1/29/2025).            II. Furosemide 20 mg IV (1/30/2025); KCl 40 mEq p.o. (1/30/2025); albumin 50 g IVPB. 6.  Primary hypertension.  Lisinopril 20 mg twice daily.  Amlodipine 5 mg daily added (1/30/2025); dose increased to 10 mg daily (2/3/2025). 7.  Type 2 diabetes mellitus.  Recommend against future use of GLP-1 agonist.  Glargine insulin decreased to 10 units daily with breakfast (2/2/2025); low-dose lispro 8.  Hyperlipidemia; hypertriglyceridemia.  Cholesterol 204, HDL 13, LDL 155, triglycerides 594 (1/21/2025), while patient prescribed atorvastatin 40 mg every evening.  Insulin clamp 10 units/hour (1/21/2025 - 1/22/2025).  Continue fenofibrate 160 mg daily (1/22/2025).  Atorvastatin 40 mg daily evening held for 1 week after d/c 9.  Prostatic hyperplasia.  Tamsulosin 0.4 mg daily. 10. Hypomagnesemia.  Magnesium 1.7 (1/22/2025); magnesium sulfate 4 g (1/22/2025).  Ongoing replacement. 11. Moderate protein calorie malnutrition.  Parenteral nutrition (1/25/20252/1/2025).  No lipids.  Patient advanced his diet. 12. Diarrhea (2/2/2025).  Repeat stool pathogen panel (2/2/2025) no pathogens found. 13. Rash (hives) on buttocks.  Suspect reaction to fentanyl.  Fentanyl PCA discontinued (2/3/2025).