Splenic Vein Thrombosis Complicating Hypertriglyceridemia-Induced Acute Pancreatitis in Diabetic Ketoacidosis: A Rare Clinical Tetrad.

Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency that may be accompanied by severe hypertriglyceridemia (HTG), particularly in patients with poorly controlled type 1 or 2 diabetes mellitus. Marked HTG is a well-recognized cause of acute pancreatitis, while splenic vein thrombosis (SVT) is an uncommon vascular complication of pancreatic inflammation. The coexistence of these four conditions represents an exceptionally rare clinical presentation. SVT is clinically significant, as it may cause sinistral portal hypertension, gastric varices, and gastrointestinal bleeding. A 34-year-old man with type 2 diabetes mellitus presented with abdominal pain, nausea, vomiting, and DKA. Initial evaluation revealed severe HTG and HTG-induced acute pancreatitis (HTG-AP), with CT showing a bulky, ill-defined pancreas, peripancreatic fluid, and fat stranding. He was initially treated with intravenous insulin, aggressive fluid resuscitation, and electrolyte replacement. Persistent abdominal pain prompted repeat CT on hospital day 3, which demonstrated isolated SVT with perigastric collaterals and no portal or superior mesenteric vein involvement. Therapeutic intravenous heparin was initiated, followed by transition to oral apixaban. He was discharged in stable condition on basal-bolus insulin, atorvastatin, fenofibrate, and omega-3 acid ethyl esters with multidisciplinary follow-up. This case describes a rare clinical tetrad linking DKA, severe HTG, HTG-AP, and SVT. It highlights the importance of early recognition and prompt multidisciplinary management of both the metabolic and thrombotic complications associated with this uncommon presentation.