A case of recurrent pancreatitis with subclavain artery stenosis: a clinical dilemma (unrelated co-existence or IgG4 related disease?) and a clinical lesson

Abstract

We report a case of a 56-year-old woman who presented with clinical features suggestive of acute pancreatitis. She had a similar episode 5 years ago. A blood pressure (BP) recording of 80/50 mmHg in the presence of acute pancreatitis led to the diagnosis of circulatory shock and vasopressors were about to be commenced. However, her overall appearance was stable and measurement of BP in the lower limbs was normal. An angiogram revealed left subclavian artery stenosis which explained the low BP reading on left arm. The patient responded to conservative management of pancreatitis, however refused further evaluation of subclavian stenosis. This case is being reported to highlight a clinical dilemma and a clinical lesson. Dilemma arises if the pancreatitis and subclavian artery stenosis is just a coincidental occurrence or it is a case of IgG4 related disease consisting of autoimmune pancreatitis (AIP) type 1 with subclavian artery stenosis a part of extra-pancreatic manifestation of the IgG4 related disease spectrum. This distinction is important in management of pancreatitis and other organ involvement. It is important to examine a patient fully and especially the vascular system - wherein all pulses are to be felt and blood pressure recorded in both sides and both limbs - whenever there is a conflict between the condition/appearance of the patient and the signs that we elicit. In this case recognising that BP was normal in the lower limbs prevented unnecessary use of vasopressors.