A 22-year-old woman with previous sub-total excision of frontal astrocytoma and residual panhypopituitarism in replacement therapy was admitted to the emergency department due to resting dyspnoea, nausea, vomiting, and diffuse abdominal pain. Upon clinical examination, the patient was hypotensive with SB (55 beats per minute—b.p.m.) as a result of a 2:1 AVB at ECG (Fig. 1). Additionally, she was dyspnoeic with type II respiratory insufficiency. Echocardiography yielded normal results. Blood tests revealed elevated serum lipase levels (590 U/L, upper reference value 160 U/L). A contrast-enhanced total body computed tomography (CT) scan demonstrated a swollen and globular pancreas with loss of typical lobulation, and diffuse fluid collection within the periglandular, periduodenal, and pararenal spaces (Fig. 2). According to the Atlanta classification [5], acute interstitial oedematous pancreatitis (AIP) was diagnosed.

ECG on admission, showing sinus rhythm 55 b.p.m. with 2:1 AVB

Abdominal contrast-enhanced CT scan, arterial phase, showing a globular pancreas increased in volume (white ✩) along with peripancreatic necrotic areas (yellow arrows)

The patient was admitted to the intensive care unit. On admission, she was hypotensive, bradycardic, with severe acute respiratory distress syndrome. Therefore, she was intubated and mechanically ventilated. An adrenal crisis secondary to AIP was diagnosed due to extremely low serum cortisol levels (14 pg/mL). Intravenous hydrocortisone was administered (50 mg i.v. every 6 h, then de-escalated). Because of acute kidney injury and oligo-anuria, her desmopressin maintenance therapy was discontinued, and crystalloid fluids and intravenous dopamine infusion were instituted to address hypotension and bradyarrhythmia. Diuretic therapy was slowly up-titrated. A repeated abdominal CT scan revealed a significant increase in peripancreatic and retroperitoneal fluid, with adipose-like areolae consistent with necrotizing pancreatitis (peripancreatic necrosis only phenotype, according to the Atlanta classification [5]). Parenteral and slow trophic enteral nutrition were carried on. The patient experienced systemic inflammatory response syndrome (SIRS) (high fever, marked increase in C-reactive protein and leucocytosis) with negative blood cultures. Abundant intravenous fluid replacement was required.

As renal function improved, a marked polyureic state along with hypernatremia ensued; as a result, diuretics were discontinued and desmopressin was re-introduced (50 µg/mL, 2 puffs ter in die). Levothyroxine dosage was augmented because of subclinical hypothyroidism.

The patient slowly improved, eventually being weaned by the respiratory and circulatory support. Blood tests indicated restoration of pancreatic and adrenal function (peak lipase levels 2231 U/L). Oral feeding was resumed. Both steroid and desmopressin therapy were de-escalated (i.e. switched to 1.5 tablet die of oral cortisone acetate 25 mg and 1 tablet ter in die of desmopressin 120 µg, respectively). Subsequent abdominal CT scans demonstrated a gradual decrease in pancreatic hypodense lesions and peripancreatic and intra-abdominal effusions, without signs of superinfection.

We suspected that the patient’s hypopituitarism could have primed AP, as no alterations in bile ducts were identified, negative viral antibodies and blood cultures excluded an infective cause, and the autoimmune panel was unsuggestive. Additionally, her serum calcium was normal and her medication history did not include drugs harmful to the pancreas.

Heart rhythm was monitored throughout the hospital stay, with the persistence of sinus rhythm along with phases of both Mobitz type II AVB (Fig. 3), 2:1 atrioventricular (AV) conduction, and advanced AVB with AV dissociation (Fig. 4). Therefore, as no reversible causes could be identified (i.e. normal electrolytes and thyroid function) and because the patient was apyretic with negative serial blood cultures, a permanent bicameral PM was implanted and programmed in DDD-40 b.p.m.

Patient’s continuous ECG monitoring with Lewis-ladder diagram: sinus rhythm with a diurnal Mobitz type II AVB episode

Patient’s ECG with Lewis-ladder diagram: sinus rhythm 37 b.p.m., advanced AVB and AV dissociation with ventricular escape rhythm (wide QRS with right bundle branch morphology, different from captured-QRS ones)

The patient was discharged after 24 days of hospitalisation. During follow-up visits, the PM interrogation showed appropriate device interventions.