Reactions 2001, p209 - 30 Mar 2024 1

Multiple drugs S

Acute pancreatitis
A 64-year-old man developed acute pancreatitis during treatment with doxycycline, aspirin, omeprazole, amlodipine and
atorvastatin for surgical site infection [not all indications stated; dosages, routes and duration of treatments to reactions onsets not
stated].
The man presented to the outpatient primary care clinic for an elliptical excision of a skin lesion of the left buttock. Eight days after
the procedure, he was found to have a surgical site infection. Initially, he was prescribed cefalexin [Keflex] for 4 days. Thereafter,
cefalexin was switched to doxycycline 12 days after the procedure for surgical site infection.He was admitted to the hospital 22 days
after the procedure (day 10 of doxycycline initiation) with acute onset of epigastric pain radiating to the back. Lipase of 6611 units/L
was noted. A CT revealed moderate peripancreatic inflammation consistent with pancreatitis. His history revealed he had not
consumed alcohol recently. Doxycycline was last taken the afternoon prior to the admission. He was diagnosed with acute
pancreatitis and was admitted. His medical history included claudication, mesenteric ischaemia, active smoker with 35 pack per
year history, coronary artery disease with prior myocardial infarction, status post 4 vessel coronary artery bypass, chronic pain
syndrome with bilateral low back pain with sciatica, chronic obstructive pulmonary disease, stable angina, renal artery stenosis,
congestive heart failure with preserved ejection fraction and chronic kidney disease stage 3. His medications included paracetamol
[acetaminophen], salbutamol [albuterol], amlodipine, aspirin, atorvastatin, cilostazol, clonidine, hydrocodone, ibuprofen,
metoprolol succinate, morphine, nitroglycerin, omeprazole, paroxetine and pregabaline. On admission, omeprazole was changed
to pantoprazole. A CT abdomen showed moderate peripancreatic inflammation consistent with pancreatitis, multiple
nonobstructive bilateral renal calculi with underlying moderate-to-severe left renal atrophy, and mild sigmoid diverticulosis. Right
upper quadrant abdominal ultrasound revealed gallbladder was surgically absent.During his hospital course, he was allowed
nothing by mouth and was treated with unspecified opioids and aggressive fluid resuscitation. His pain improved and he started a
clear liquid diet on day 3 of hospitalisation. His aspirin and ibuprofen were discontinued. On hospital day 4, he was noted to have
worsening dyspnoea and increasing oxygen requirement. A diagnosis of aspiration pneumonia was made. He then started
receiving cefepime and vancomycin for aspiration pneumonia. On day 5, supplemental oxygen needs decreased. On day 6, he
started a fat-restricted diet and was given metronidazole due to a elevated WBC count and concern for abdominal infection. Repeat
abdominal CT scan to evaluate for infection on day 7 revealed mild pancreatitis, which was felt to be improving compared to
admission CT. He experienced improvement with antibacterials [antibiotics] and on a fat-restricted diet during the
hospitalisation.On hospital day 9, he was discharged with cefdinir for 7 days for hospital-acquired aspiration pneumonia. On follow-
up about 8 weeks after discharge, his primary care clinician indicated he had weaned off his chronic unspecified opioids and had
some mild, intermittent residual abdominal pain. A lipase checked at this time was normal. However, he died due to an acute
myocardial infarction about 16 weeks after admission. Finally, his acute pancreatitis was attributed to doxycycline, aspirin,
omeprazole, amlodipine and atorvastatin.
Kakes J, et al. A Case of Doxycycline-Induced Pancreatitis. Wisconsin Medical Journal 123: 43-47, No. 1, Feb 2024. Available from: URL: https://wmjonline.org/wp-content/
uploads/2024/123/1/43.pdf 803849630