Case Presentation: 81 YO M patient with medical history significant of Type 2 diabetes mellitus, hypertension and hypothyroidism presented to the emergency room in the month of October with the complaints of abdominal pain and nausea for 1 day, progressively worsened, constant, with no relieving factors. His social determinants included one glass of wine or a beer socially on weekends, no smoking or recreational drugs. His medications included (Aspirin, Amlodipine, Atenolol, Lipitor, Vitamin B12, Vitamin D, Levothyroxine, Glimepiride and Montelukast) which he has been taking for years. He had a flu vaccine 4 days prior to the presentation to the emergency room.The blood work was significant for Hg of 10.7 and Lipase of >2250, rest of the blood count and chemistry was within normal range. Ultrasound of right upper quadrant was unremarkable with no cholelithiasis. CT scan abdomen and pelvis showed no evidence of acute pancreatitis. Patient was diagnosed with acute pancreatitis based on the clinical presentation and blood work.As a part of the work up, his triglycerides were checked, which was within normal limits at 164, his IgG4 was also done to rule out autoimmune pancreatitis and the level was 20.2(within normal limits). He was admitted in the hospital and managed conservatively with IVF and appropriate pain control. His diet was slowly advanced, and he improved and was discharged home.
Discussion: Acute pancreatitis is an acute inflammatory process of the pancreas and should be suspected in patients with severe acute upper abdominal pain.The diagnosis of acute pancreatitis requires the presence of two of the following three criteria: acute onset of persistent, severe, epigastric pain often radiating to the back, elevation in serum lipase or amylase to three times or greater than the upper limit of normal, and characteristic findings of acute pancreatitis on imaging (contrast-enhanced computed tomography [CT], magnetic resonance imaging [MRI], or transabdominal ultrasonography.In patients with characteristic abdominal pain and elevation in serum lipase or amylase to three times or greater than the upper limit of normal, no imaging is required to establish the diagnosis of acute pancreatitis.Extensive review of the medical literature shows that there are a few cases of acute pancreatitis reported after administration of seasonal flu vaccine and a few cases of severe acute pancreatitis with multi organ dysfunction have been reported after H1N1 influenza infections. In all these cases the most common causes of acute pancreatitis such as Alcohol, Gall stones, hyper triglyceridemia, medications and other fewer common causes were excluded by detailed history and laboratory work, like the case in our patient.The exact cause of acute pancreatitis following an influenza vaccine is still unknown, however, the report published by the Canadian Medical Association theorized that the mechanism could be autoimmune-related (1,6).
Conclusions: Although there is not much literature available to prove the association between influenza vaccine and pancreatitis, but certainly we have the cases that have been reported, where all other possible precipitating factors have been ruled out as a cause of pancreatitis. The above case would also compel the providers to think about acute pancreatitis, as a rare but possible side effect of influenza vaccine.