(3.06) A Case of Fatal Fulminant Necrotizing Pancreatitis in a Patient with Recent Tirzepatide Initiation

Introduction : Tirzepatide is frequently used for weight loss benefits in patients with obesity without diabetes. It is rarely associated with acute pancreatitis. However, there are no case reports documenting fulminant necrotizing pancreatitis resulting in fatality in conjunction with tirzepatide use. We present a case of fatal fulminant necrotizing pancreatitis in a low-risk patient with recent tirzepatide initiation.

Case(s) Description : A 64-year-old female with hypertension, hyperlipidemia, and class 1 obesity arrived at the emergency department with sudden onset epigastric pain. She recently started tirzepatide for weight loss, and her last dose was four days prior to presentation. She reported alcohol use (one to two glasses of wine, three times per week) with her last drink three days prior. Vitals were significant for tachypnea and hypertension. Physical exam demonstrated diffuse abdominal pain with guarding.

On admission, abnormal labs included a lipase of 8195 U/L (normal range 13-60), glucose of 234 mg/dL (70-140), hemoglobin of 17.7 g/dL (11.6-15.0), and white blood cell count of 18.9 x 10⁹/L (3.4-9.6 x 10⁹). Liver enzymes, bilirubin, triglycerides, and cholesterol were all within normal limits. Computerized tomography (CT) scan of the abdomen and pelvis showed acute pancreatitis and evidence of partial possible necrosis of the pancreatic body. She was admitted and initiated on intravenous fluids and pain control medications.

On day two, CT showed worsening of severe necrotizing pancreatitis and new hypoperfusion of several organs. Labs showed elevated aspartate aminotransferase of 2245 U/L (8-43) and alanine aminotransferase of 1559 U/L (7-45). The patient developed acute hypoxic respiratory failure requiring intubation with mechanical ventilation and hypotension requiring four vasopressors. Evening labs showed new metabolic acidosis and concern for disseminated intravascular coagulation. She received packed red blood cells and platelets. The hospital course was further complicated by an Enterococcus faecalis urinary tract infection and antibiotics were initiated. She became oliguric, and continuous renal replacement therapy was initiated.

On day three, the patient continued to decline. She developed asymmetric pupils, and stroke protocol was initiated. Prior to brain imaging, she developed asystole and was pronounced deceased. Preliminary autopsy results were significant for necrotic pancreas with hemorrhagic changes.

Discussion :

While tirzepatide has known significant weight loss benefits, physicians should be aware of the rare but potentially fatal side effects before initiating treatment. A case-by-case risk benefit analysis should be performed for each patient. The importance of this should be emphasized by making necrotizing pancreatitis a boxed warning for tirzepatide.