Clinical challenges to determine chronic pancreatitis and sialadenitis cause for a multimorbid patient with a suspected eating disorder

Abstract

Background: Multimorbidity is two or more coexisting diseases in an individual and it is a growing global challenge. Some studies show the potentially increased risk of multimorbidity for people with eating disorders. We present a case of a multimorbid female who has symptoms that might be related to IgG4 disease or bulimia. Case report: A 41-year-old female was hospitalized due to white liquid stools, whole body itching, sialadenitis, leg swelling and paresthesia. Cachectic body composition, multiple rashes and dry skin was noticed, the patient weight was 35 kg and height 171 cm. Bulimia was suspected because of her weight, symptoms and behavior. The patient has osteoporosis, had acute pancreatitis episode, has chronic pancreatitis with endocrine and exocrine pancreatic insufficiency, chronic autoimmune thyroiditis, type 2 diabetes, axonal sensory polyneuropathy, has persistent hypokalemia, chronic renal disease, secondary hyperaldosteronism and has recurrent bleeding from digestive tract. Increased IgG4 levels in blood was found but then there were not enough evidences for IgG4 disease. The patient’s lab tests showed hypokalemia, decreasing alpha amylase levels, hypoalbuminemia and hypoproteinemia. The patient was complaining with sore throat, rhinorrhea and fever, but inflammatory tests were normal. Ultrasound of salivary glands showed significant enlargement of glands, biopsy was also done but no pathology was noticed. Abdominal ultrasound showed atrophic pancreas with multiple calculi and DEXA scan showed persistent osteoporosis. Glucocorticoids could not be described due to suspicion of viral infection. Because of stable condition the patient was discharged from the hospital with a diet plan and treatment recommendations. Appointment with a gastroenterologist was planned to determine further treatment tactics with glucocorticoids and differentiation between IgG4 disease caused chronic pancreatitis and sialadenitis and idiopathic pancreatitis and bulimia. Conclusions: This case report shows the complexity of the diagnostic and treatment process for clinicians who treat multimorbid patients. As in this case, the patient had multiple complaints related to digestive system and other organ systems diseases, had suspected eating disorder and was and still is a real challenge requiring further multidisciplinary examination and evaluation in order to prescribe adequate treatment for her conditions.