S5977 Acute Necrotizing Pancreatitis Presenting With Altered Mental Status: A Case Report

Introduction: Acute necrotizing pancreatitis (ANP) is well documented in adult patients; however, it is rare in the pediatric population. Despite its rarity, ANP in children is associated with significant morbidity, including prolonged hospitalizations averaging 20 days, with some cases requiring intensive care. Complications can involve multiple organ systems, highlighting the need for early recognition and intensive medical management. Case Description/Methods: A previously healthy 4-year-old male presented with altered mental status (AMS) and was diagnosed with acute necrotizing pancreatitis (ANP). He had <24 hours of abdominal pain and AMS, described by his parent as not “acting like himself.” Initial labs showed leukocytosis and thrombocytosis; brain imaging, cerebrospinal fluid CSF) studies, and drug screening were normal. An abdominal ultrasound revealed pancreatitis with complex fluid, and lipase was elevated at 1783 U/L. He was admitted to the pediatric intensive care unit for concern of compensated septic shock. Magnetic resonance imaging (MRI) was deferred due to respiratory distress, and computed tomography (CT) confirmed necrotizing pancreatitis. His course was complicated by pleural effusions and splenic vein thrombosis, requiring diuretics, anticoagulation, antibiotics, and bowel rest with total parenteral nutrition (TPN). He gradually improved and was discharged in stable condition with normalized lipase and follow-up with gastroenterology. Discussion: Acute ANP is a rare but severe form of pediatric acute pancreatitis (AP), occurring in less than 1% of cases and associated with significant morbidity. This case is notable for initial presentation with AMS, a rare symptom in pediatric AP that may reflect early systemic inflammation or multi-organ dysfunction. Normal neurologic imaging and CSF, along with rapid improvement after fluid resuscitation, suggest a hemodynamic or inflammatory cause. Although MRI is preferred in children, instability required contrast-enhanced CT, which confirmed necrosis. The patient’s course was complicated by pleural effusions, limiting the use of intravenous fluids and splenic vein thrombosis, necessitating anticoagulation. Management included PICU-level care with fluids, antibiotics, TPN, and bowel rest. While early enteral nutrition is generally favored, TPN was necessary due to persistent symptoms. This case emphasizes the importance of recognizing atypical signs of ANP and the need for individualized, multidisciplinary care.