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Pancreatic encephalopathy—a rare complication of a common disease
European Journal of Internal Medicine 17 (2006) 382 www.elsevier.com/locate/ejim
Letter to the Editor
Pancreatic encephalopathy—a rare complication of a common disease Peter Bartha a, Ella Shifrin b, Yishai Levy a,* a
b
Department of Internal Medicine D, Rambam Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa 35254, Israel Department of Neurology, Rambam Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel Received 15 December 2005; accepted 16 January 2006
Keywords: Acute pancreatitis; Cognitive impairment; Pancreatic encephalopathy
A 49-year-old woman was admitted to the Department of Surgery for laparoscopic cholecystectomy. Abdominal images confirmed the diagnosis of a solitary gallbladder stone. Laparoscopic cholecystectomy was performed. The patient was re-admitted a month later with abdominal pain and vomiting. An abdominal CT showed severe necrotizing pancreatitis. Concomitantly, significant trunk and gait ataxia and behavioral changes occurred. Psychomotor retardation became profuse, the patient did not initiate speech or movement, and comprehension was restricted to two commands. Repetition of four-word sentences was intact and preservation occurred while trying to reply. She was not oriented to place or time, digit span was 3 digits forwards (normal 6) and none backwards (normal 4), and she was unable to perform serial subtractions (take 7 away from 100). Evaluation of CSF chemistry, cytology, VDRL, oligoclonal bands, and 14-3-3 protein did not reveal pathology. Brain CT with and without contrast, and MRI with and without gadolinium were within the normal ranges. The diagnosis of an acute encephalopathy was suggested. After being placed on a low-fat diet, a slow but fluctuating improvement in neuropsychiatric status ensued with further improvement in abdominal CT. The patient returned to her basal state 5months after admission and was discharged for rehabilitation. Although it has been reported for more than 60 years, the largest retrospective series of cases of pancreatic encephalopathy was published recently by Ding et al. [1] on 24 patients from China. Biliary and alcoholic pancreatitis were * Corresponding author. Tel.: +972 4 8542263; fax: +972 4 8543286. E-mail address: [email protected] (Y. Levy).
the most common etiologies, onset was usually within 2 weeks of diagnosis of pancreatitis, and the most common manifestations were delirium, hallucinations, convulsive and/or focal seizures, weakness, dysarthria, rigidity, and hemi-syndrome. Mortality was high (11 out of 24 patients). EEG and brain CT are usually non-specific. The longest follow-up of a case (7 years) was marked by alternating focal signs and cognitive impairment [2]. The pathogenesis of pancreatic encephalopathy is still elusive, especially when no ischemic or metabolic abnormalities can be associated with the condition, as was the case with our patient. CNS leakage of pancreatic enzymes and increased systemic inflammatory cytokines are suggested. Treatment is mainly supportive. We have communicated this case report because we are of the opinion that neurocognitive assessment in the course of acute pancreatitis with neuropsychiatric signs and symptoms warrants a special reference and discussion.
Acknowledgement The authors wish to thank Ms. Iris Cohen, Department of Medicine D, for preparing the manuscript.
References [1] Ding X, Liu CA, Gong JP, Li SW. Pancreatic encephalopathy in 24 patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int 2004;3:608 – 11. [2] Ruggieri RM, Lupo I, Piccoli F. Pancreatic encephalopathy: a 7-year follow-up case report and review of the literature. Neurol Sci 2002;23:203 – 5.
0953-6205/$ - see front matter D 2006 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2006.01.002
Letter to the Editor
Pancreatic encephalopathy—a rare complication of a common disease Peter Bartha a, Ella Shifrin b, Yishai Levy a,* a
b
Department of Internal Medicine D, Rambam Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa 35254, Israel Department of Neurology, Rambam Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel Received 15 December 2005; accepted 16 January 2006
Keywords: Acute pancreatitis; Cognitive impairment; Pancreatic encephalopathy
A 49-year-old woman was admitted to the Department of Surgery for laparoscopic cholecystectomy. Abdominal images confirmed the diagnosis of a solitary gallbladder stone. Laparoscopic cholecystectomy was performed. The patient was re-admitted a month later with abdominal pain and vomiting. An abdominal CT showed severe necrotizing pancreatitis. Concomitantly, significant trunk and gait ataxia and behavioral changes occurred. Psychomotor retardation became profuse, the patient did not initiate speech or movement, and comprehension was restricted to two commands. Repetition of four-word sentences was intact and preservation occurred while trying to reply. She was not oriented to place or time, digit span was 3 digits forwards (normal 6) and none backwards (normal 4), and she was unable to perform serial subtractions (take 7 away from 100). Evaluation of CSF chemistry, cytology, VDRL, oligoclonal bands, and 14-3-3 protein did not reveal pathology. Brain CT with and without contrast, and MRI with and without gadolinium were within the normal ranges. The diagnosis of an acute encephalopathy was suggested. After being placed on a low-fat diet, a slow but fluctuating improvement in neuropsychiatric status ensued with further improvement in abdominal CT. The patient returned to her basal state 5months after admission and was discharged for rehabilitation. Although it has been reported for more than 60 years, the largest retrospective series of cases of pancreatic encephalopathy was published recently by Ding et al. [1] on 24 patients from China. Biliary and alcoholic pancreatitis were * Corresponding author. Tel.: +972 4 8542263; fax: +972 4 8543286. E-mail address: [email protected] (Y. Levy).
the most common etiologies, onset was usually within 2 weeks of diagnosis of pancreatitis, and the most common manifestations were delirium, hallucinations, convulsive and/or focal seizures, weakness, dysarthria, rigidity, and hemi-syndrome. Mortality was high (11 out of 24 patients). EEG and brain CT are usually non-specific. The longest follow-up of a case (7 years) was marked by alternating focal signs and cognitive impairment [2]. The pathogenesis of pancreatic encephalopathy is still elusive, especially when no ischemic or metabolic abnormalities can be associated with the condition, as was the case with our patient. CNS leakage of pancreatic enzymes and increased systemic inflammatory cytokines are suggested. Treatment is mainly supportive. We have communicated this case report because we are of the opinion that neurocognitive assessment in the course of acute pancreatitis with neuropsychiatric signs and symptoms warrants a special reference and discussion.
Acknowledgement The authors wish to thank Ms. Iris Cohen, Department of Medicine D, for preparing the manuscript.
References [1] Ding X, Liu CA, Gong JP, Li SW. Pancreatic encephalopathy in 24 patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int 2004;3:608 – 11. [2] Ruggieri RM, Lupo I, Piccoli F. Pancreatic encephalopathy: a 7-year follow-up case report and review of the literature. Neurol Sci 2002;23:203 – 5.
0953-6205/$ - see front matter D 2006 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2006.01.002