Fulminant pancreatic encephalopathy with brain edema and herniation in severe hypertriglyceridemia-induced pancreatitis: a case report

Pancreatic encephalopathy (PE) is a rare but potentially devastating neurological complication of severe acute pancreatitis. Its manifestations range from confusion and agitation to seizures, coma, and cerebral edema, often making the diagnosis challenging due to its overlap with other causes of encephalopathy. We report a 23-year-old woman with hypertriglyceridemia-induced acute pancreatitis who rapidly progressed to severe acute pancreatitis with multiorgan failure. Within 48 h of admission, she developed agitation, seizure-like activity, and coma. Neuroimaging demonstrated diffuse cerebral and cerebellar edema, features of elevated intracranial pressure, cerebellar tonsillar herniation, and extensive restricted diffusion. After evaluation of alternative etiologies, the neurological deterioration was attributed to PE. Despite aggressive medical management, including insulin therapy, renal replacement therapy, mechanical ventilation, and hyperosmolar therapy, she did not show any signs of neurological recovery. This case demonstrates that PE may rarely progress to malignant cerebral edema and tonsillar herniation. New neuropsychiatric manifestations in patients with severe acute pancreatitis should prompt urgent neurological assessment and early neuroimaging whenever clinically feasible.