S3267 Acute Presentation of Infected Pseudocyst

Introduction: Pancreatic pseudocysts are encapsulated fluid collections, usually arising weeks after pancreatitis—more often in chronic cases. Though many resolve spontaneously, complications like infection, hemorrhage, ascites, or GI obstruction may occur. Infection, while rare, is serious and necessitates prompt intervention. Case Description/Methods: A 71-year-old woman with a complex medical history—severe acute pancreatitis, pneumonia, C. difficile infection, new-onset atrial fibrillation, hypertension, hyperlipidemia, chronic kidney disease, and spinal stenosis—presented with septic shock. She had recently been discharged from the hospital and transferred to a skilled nursing facility, with plans to return home. At the airport, her daughter noticed altered mental status and weakness. In the ED, the patient denied fever, abdominal pain, or urinary symptoms, but was hypotensive (BP 62/40 mmHg). She was started on sepsis protocol: IV fluids, empiric antibiotics (Zyvox, vancomycin), and vasopressors. Labs showed WBC 22.7, Hb 10.4, Na 130, bicarbonate 14, Cr 1.73, AST 43, ALP 337, and lactate 5.44. Chest X-ray showed bilateral effusions and pulmonary congestion. Non-contrast computed tomography of the chest/abdomen/pelvis revealed large pleural effusions, ascites, fatty liver, and a sizable pancreatic pseudocyst. Gastroenterology and surgery were consulted, and interventional radiology drained the pseudocyst. Cultures grew Escherichia coli, confirming infection. Post-drainage, her WBC normalized, hemodynamics improved, vasopressors were discontinued, and she was discharged. Discussion: Infected pseudocysts are uncommon and typically linked to chronic pancreatitis. In this case, the infection developed more than 5 weeks after an acute episode—a delayed and unusual progression. The patient’s lack of classic symptoms (fever, abdominal pain) complicated early recognition. Sepsis was identified via hemodynamic instability and lab abnormalities rather than clinical signs. This highlights the importance of continued monitoring after severe pancreatitis and the subtle presentations in older or immunocompromised individuals. Imaging and culture of the drained fluid were critical to diagnosis. E. coli, though typical of gastrointestinal infections, is rare in pancreatic pseudocysts. This case emphasizes the need to include infected pseudocyst in the differential for sepsis following pancreatitis, even without abdominal complaints. Multidisciplinary coordination—particularly gastroenterology, surgery, and IR—was essential in achieving a positive outcome.