Severe Recurrent Pancreatitis in a Child with ADHD after Starting Treatment with Methylphenidate (Ritalin)

We present a case of a 10-year-old boy, who had severe relapsing pancreatitis, three times in two months within 3 weeks after starting treatment with methylphenidate (Ritalin) due to attention deficit hyperactivity disorder (ADHD). Pancreatitis due to the use of (methylphenidate) Ritalin was never published before. Attention must be made by the physicians regarding this possible complication, and this complication should be taken into consideration in every patient with abdominal pain who was newly treated with Ritalin. 1. Case Presentation A case of a 10-year-old boy was referred to emergency department because of an abrupt onset of aggravating abdominal pain and vomiting. The boy was generally healthy except for that he was newly diagnosed with ADHD and started the use of methylphenidate (Ritalin) for the past three weeks at a dose of 30？mg daily. Physical examination on admission revealed that the boy looks suffering and afebrile and has diffuse tenderness of abdomen without rebound and no dyspnoea. Laboratory tests showed high level of serum amylase 5824？U/L (amylase normal value: 30–110？U/L), high level of lipase 1950？U/L (normal value: 10/140？U/L), high levels of liver enzymes, AST 1259 (normal range 5–43), ALT 769 (normal range 5–40), and normal levels of electrolytes, cholesterol, triglycerides, bilirubin. There was no metabolic acidosis. Ultrasound of abdomen (Figure 1(a)) showed edematous and enlarged pancreas, big amount of free fluid in the abdomen (Figure 1(b)), thickened gallbladder wall up to 6？mm without intraluminal stones (Figure 2), and no intrahepatic or extrahepatic biliary dilatation. There was no anamnestic familial history of pancreatitis. Figure 1: (a) Ultrasound of epigastrium region showing edematous pancreas (white arrows) and (b) ultrasound of lower abdomen showing free fluid (blue arrow). Figure 2: Ultrasound of the right upper quadrant showing the gallbladder free of stones (blue arrow) and thickening of gallbladder wall (white arrows). The boy was admitted to intensive care unit with the diagnosis of acute pancreatitis and was started workup to investigate the etiology which revealed no alcohol use, transesophageal ultrasound (EUS) followed by magnetic resonance cholangiopancreatography (MRCP) (Figure 3) no biliary stone or any congenital or acquired malformation, and normal levels of immunoglobulins which excluded autoimmune pancreatitis. Other possible causes such as viral, bacteria, and parasites screening were all negative. Figure 3: Coronal T2 MRI (as part of the MRCP STUDY) showing no dilatation and normal position