70 years male, with history of type 2 Diabetes mellitus, Hypertension, Bronchial asthma, Ischemic Heart Disease – S/P PTCA, history of pancreatitis 10 years back, admitted with epigastric pain and vomiting. Blood investigations showed elevated triglycerides 2089 mg/dl, lipase 8383 U/L, amylase 1423 U/L & Prothrombin time > 200. He was adequately hydrated and treated with Fenofibrate.  On 4^th day of admission, he developed sudden right sided weakness lasting for few minutes. Immediate CT Brain and angiogram was unremarkable. Within one hour, he had weakness of both lower limbs. He was initiated on low molecular weight heparin and Aspirin. Later on the same day, he had sudden deterioration in GCS and respiratory distress, associated with tachypnea, tachycardia and developed petechial rash over his chest. Neurological examination showed weakness of all 4 limbs, power on left (Grade 1/5) and on right (Grade 4/5) with hypotonia. Repeat MRI Brain showed star field pattern of hyperintensities suggestive of fat embolism in the setting of hypertriglyceridemia and acute pancreatitis. He was treated with Inj. Methylprednisolone and required intubation and ventilator support, later with tracheostomy he was weaned off from ventilator support. Patient was decannulated a month later and his weakness got better with physiotherapy.

MRI Brain (DWI) images showing multiple hyperintensities (Starfield pattern) in bilateral cerebral and cerebellar/ left paramedian pons suggesting microinfarcts – Fat embolism in the context of hypertriglyceridemia and acute pancreatitis.

Contributors: Gayathri Ram (Physician Assitant),Dr. Bhuvaneshwari Rajendran (Neurologist), Dr. Sridhar Nadigan (Intensivist), Dr. Babu Peters (Radiologist)

Dr. Bhuvaneshwari Rajendran
Senior Consultant – Neurology and Neurophysiology
Kauvery Hospital