S3238 Stones, Steatosis, and Surprises: A Rare Case of Pancreatitis in Common Variable Immunodeficiency

Introduction: Common variable immunodeficiency (CVID) is the most frequent symptomatic primary immunodeficiency, marked by impaired antibody production. Although gastrointestinal (GI) complications are frequent, particularly enteropathy and infections, biliary and pancreatic involvement is rarely reported. This case highlights a rare co-presentation of acute pancreatitis and cholelithiasis in a young woman with CVID. Case Description/Methods: A 26-year-old woman with CVID on immunoglobulin (Hizentra), metabolic-associated cirrhosis and asthma presented with 3 days of diffuse abdominal pain, diarrhea, nausea, and vomiting. Labs revealed leukocytosis, transaminitis and lipase 1519 U/L. Abdominal ultrasound showed gallstones with wall thickening and a positive Murphy sign. Magnetic resonance imaging revealed hepatic steatosis, gallstones without biliary dilation, and generalized mesenteric edema. No pancreatic mass or ductal irregularity was seen. She was managed conservatively and underwent cholecystectomy. Post surgery, her symptoms subsided, and her labs normalised. Discussion: GI manifestations occur in upto 20% of CVID cases, often mimicking inflammatory bowel disease or celiac disease. Pancreatitis is rarely described, usually in immune dysregulation (e.g., LRBA deficiency) or autoimmunity. Gallbladder disease is more commonly reported in pediatric CVID, especially with autoimmune hemolytic anemia or chronic inflammation. Chronic immune activation, hepatobiliary inflammation, or lipid metabolism issues may contribute. While gallstones caused her pancreatitis, cirrhosis and immune dysfunction likely played a role. This case emphasizes the need to maintain a broad differential in CVID patients with abdominal pain, including pancreatobiliary etiologies.