Case Presentation: A 90-year old female with a medical history of atrial fibrillation, CAD and COPD presented with progressively worsening abdominal pain, nausea and vomiting for the past 3 weeks, which had acutely worsened over the past 1 week. She described the pain as epigastric with radiation to her right flank. Symptoms were aggravated on eating food, and recently even with fluids. She had not been able to keep anything down for the past few days secondary to nausea and noted significant weight loss and weakness. Examination revealed an elderly woman who appeared dehydrated, with severe epigastric pain on light palpation. Laboratory findings were significant for an elevated lipase of 551, triglycerides within normal limits. CT Abdomen revealed fat stranding around the pancreatic head and uncinate process, with duodenal wall thickening – Suggestive of acute groove pancreatitis. Notably, the patient was status post cholecystectomy, without biliary dilation. She denied any recent alcohol use. Significantly, the patient was prescribed a 14-day course of doxycycline for CAP, which she recently completed. The onset of gastrointestinal symptoms began shortly after beginning this medication. Her hospital course was uneventful, and she was able to tolerate a clear liquid diet 5 days after admission. She noted having had pancreatitis once before in her life, also after receiving an unknown antibiotic. She was discharged home after a 10-day hospital course in good health. Alternative explanations for her pancreatitis were explored and were unrevealing, leading us to the diagnosis of drug-induced pancreatitis.
Discussion: Doxycycline-induced pancreatitis is a very uncommon, but well-described entity in clinical medicine. Groove pancreatitis itself is a very rare condition as well, characterized by inflammation of the area between the head of the pancreas, the duodenum, and the common bile duct. The clinical presentation of groove pancreatitis can vary greatly in its acuity, and although some patients can have a presentation similar to that of acute pancreatitis, most have a more chronic disease course. It has been almost exclusively described in middle-aged men secondary to alcohol abuse and is characterized by marked nausea secondary to duodenal thickening and stricture formation. These two rare clinical entities have never been previously described as having occurred simultaneously before. We describe a case of DIP in a 90-year old female following outpatient management of Community-acquired pneumonia.
Conclusions: Drug-induced pancreatitis is a far less common etiology for acute pancreatitis compared to gallstones, alcohol, hypertriglyceridemia, and trauma. Clinical suspicion for this entity should remain particularly high in cases without a clear inciting cause. Gathering a thorough history may prove critical in clinching the diagnosis. Also notable is that while groove pancreatitis is almost always described as being chronic in nature and secondary to alcoholism, it may present acutely and in patients not fitting the typical patient characterization.