CASE REPORT |
https://doi.org/10.5005/jp-journals-10089-0077 |
A Rare Case of Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome Causing Acute Pancreatitis
1–4Department of Critical Care Medicine, Apollo Hospital Sheshadripuram, Bengaluru, Karnataka, India
Corresponding Author: Pradeep M Venkategowda, Department of Critical Care Medicine, Apollo Hospital Sheshadripuram, Bengaluru, Karnataka, India, Phone: +91 8897575704, e-mail: drpradeepmarur@gmail.com
Received on: 17 July 2023; Accepted on: 27 September 2023; Published on: 30 October 2023
ABSTRACT
Most cases of acute pancreatitis (AP) in pregnancy are attributed to gallstones. The hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome causing AP is very rare. This is a case of a 26-year-old female who had a normal delivery 2 days back following a full-term pregnancy complicated with preeclampsia (PE). She presented to our hospital with a history of pain abdomen, fever, and vomiting for 2 days. She had PE for which she was treated with tablets aspirin and labetalol. Routine investigations revealed thrombocytopenia, hemolysis, elevated alanine aminotransferase (ALT), and aspartate aminotransferase (AST) suggestive of HELLP syndrome. Blood investigation revealed elevated serum amylase and lipase levels along with computed tomography (CT) of the abdomen suggestive of AP. She was diagnosed to be having HELLP syndrome-associated AP and was managed conservatively. The patient’s condition and lab parameters improved gradually and discharged home in stable condition. This case report highlights a rare case of HELLP syndrome causing AP.
How to cite this article: Chiranjeevi AS, Nagaraja VM, Venkategowda PM, et al. A Rare Case of Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome Causing Acute Pancreatitis. J Acute Care 2023;2(2):74–76.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Case report, Hemolysis, elevated liver enzymes, and low platelets syndrome, Pain abdomen, Pancreatitis, Pregnancy
INTRODUCTION
Acute pancreatitis (AP) is one of the leading causes of hospital admission in the gastroenterology department.1 The incidence of pancreatitis is about 4.9–35/100,000 general population.2 Gallstone and alcohol consumption are the two leading (about two out of three) causes of AP.3-5 In pregnancy the most common cause of AP is gallstones. It is usually observed during the third trimester or early postpartum period. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome [which is seen in 10–20% of cases of severe preeclampsia (PE)] as a cause of AP during pregnancy or postpartum is very rare. This is a case report of HELLP syndrome associated AP, early diagnosis and management can reduce morbidity and mortality.
CASE DESCRIPTION
This is a case of a 26-year-old female patient pregnancy1living1 abortion1 who had normal delivery 2 days back following a full-term pregnancy complicated with PE. She presented to a tertiary care hospital with complaints of pain abdomen, fever, and vomiting for 2 days. There was no history of headache, blurring of vision, seizures, chest pain, cough, decreased urine output, and bleeding manifestations. The patient has a known case of hypothyroidism on oral thyroxine replacement therapy and pregnancy-induced hypertension on oral labetalol 100 mg twice daily and oral aspirin 75 mg once daily. The patient was initially evaluated elsewhere and was referred to a tertiary care hospital in view of suspected HELLP syndrome. On examination in the emergency room, the patient was febrile with a temperature of 100.5°F, heart rate—130/minute, blood pressure (BP)—142/90 mm Hg, saturation of peripheral oxygen—97% on oxygen at 7–8 L/minute, and respiratory rate—20/minute. The patient was conscious, alert, and cooperative. Systemic examination revealed bilateral fine crepitations on auscultation as well as tenderness and guarding in the epigastric and left upper quadrant of the abdomen. Blood investigations revealed hemoglobin—10.7 gm/dL, hematocrit—33%, total leukocyte count—12,300/μL, platelet count—38,000/μL, and peripheral smear showed normocytic normochromic anemia with severe thrombocytopenia. Serum creatinine—0.74 mg/dL, uric acid—6.9 mg/dL, total bilirubin—1.3 mg/dL, indirect bilirubin—1.0 mg/dL, serum aspartate aminotransferase (AST)—74 U/L, alanine aminotransferase (ALT)—22 U/L, lactate dehydrogenase (LDH)—1074 U/L, elevated levels of serum amylase (227U/L), and serum lipase (462 U/L). The tropical infection workup was negative. The lipid profile and serum calcium were normal. Other lab parameters were normal except for positive urine proteins. Ultrasonography abdomen did not show any evidence of cholelithiasis/choledocholithiasis. Sepsis was ruled out as our patient had normal procalcitonin levels, no foci of infection on examination, and negative blood and urine cultures. Contrast-enhanced computed tomography (CECT) abdomen was done which revealed AP with ill-defined peripancreatic collection with CT severity score-6 along with mild ascites, omental fat stranding, and bilateral mild pleural effusion (Fig. 1). Hence, HELLP syndrome induced AP with systemic inflammatory response syndrome was diagnosed. Other causes of AP were ruled out and the patient was managed conservatively with Intravenous (IV) fluids and analgesics. The patient’s lab parameters improved gradually and was shifted to the ward on 4th day. Platelet counts improved to 130,000/μL after 7 days and the patient was discharged home in stable condition without any symptoms.
Fig. 1: CECT abdomen showing edematous pancreas with ill-defined peripancreatic collection suggestive of AP
DISCUSSION
The inflammation of the pancreas is known as pancreatitis. To diagnose pancreatitis, we need two out of three features such as pain abdomen, raised pancreatic enzymes, and radiological features suggestive of pancreatic inflammation. Gallstone and alcohol consumption are the two leading (about two out of three) causes of AP.3-5 AP in pregnancy is rare and the most common cause is biliary (gallstone) related.
Preeclampsia (PE) is defined as BP ≥ 140/90 mm Hg after 20 weeks of gestation with associated proteinuria (>300 mg/day). When associated with high BP ≥ 160/110 mm Hg along with thrombocytopenia, pulmonary edema, elevated liver enzymes, and serum creatinine, it is called severe PE.6 Our patient also had PE during the third trimester of pregnancy and was treated with labetalol and aspirin. HELLP syndrome belongs to the condition of hypertensive disorders of pregnancy (which also includes PE and eclampsia).7 The mechanism for the above complications can be due to microangiopathy and vasospasm causing alteration in microcirculation8 which leads to end organ damage. PE is seen in 3–5% of all pregnancies9 and HELLP syndrome is seen in 10–20% of cases of severe PE.
The HELLP syndrome can be identified using the Tennessee and Mississippi classifications. Tennessee classification includes—(1) evidence of microangiopathic hemolytic anemia, (2) AST >70 IU/L, and (3) platelet count <100,000/μL. The Mississippi classification has three types based on platelet count. Complications of HELLP syndrome—disseminated intravascular coagulation (DIC), abruption placenta, hepatic rupture, acute kidney injury (AKI), retinal detachment, and vitreous hemorrhage. Rarely it can cause pancreatitis.10-14 Pancreatitis can be due to a combination of severe inflammation microangiopathy-related ischemia and vasospasm and elevated levels of nuclear factor κ-B.
The clinical features include pain abdomen, vomiting, and abdominal distension. Our patient had pain abdomen and vomiting 2 days following normal delivery. Our patient had a low platelet count (38,000/μL), evidence of hemolysis (LDH—1,074 IU/L), and elevated AST levels (74 U/L) suggestive of HELLP syndrome which belongs to Mississippi classification class-I (platelet count < 50,000/μL, AST/ALT ≥ 70 IU/L, and LDH ≥ 600 IU/L). The elevated serum amylase and lipase levels along with CT abdomen findings were suggestive of AP. She was diagnosed to be having HELLP syndrome associated with AP.
The treatment of HELLP syndrome-related pancreatitis is usually conservative. Our patient was also managed conservatively with adequate IV hydration, analgesics, oxygen, anticoagulants, and other supportive care. The patient’s condition and lab parameters improved gradually and discharged home in stable condition.
This case report is a rare case of HELLP syndrome associated with AP and emphasizes early diagnosis with timely supportive care for reducing morbidity and mortality.
ACKNOWLEDGMENT
We acknowledge medical gastroenterologists, gynecologists, general surgeons, nurses, and management of the hospital for their valuable support.
ORCID
Adithya S Chiranjeevi https://orcid.org/0009-0003-4421-2582
Varun M Nagaraja https://orcid.org/0000-0003-2400-7533
Pradeep M Venkategowda https://orcid.org/0000-0001-6544-0355
Jayalakshmi M Manjunath https://orcid.org/0000-0002-7730-8789
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