When seizure control comes at a cost: valproic acid-induced necrotising pancreatitis in a patient receiving antiepileptic polypharmacy.

We present a case of a man in his late 20s with psychiatric and metabolic comorbidities who developed acute necrotising pancreatitis in the setting of antiepileptic polypharmacy, including valproic acid. The patient presented with nausea, vomiting and progressive lethargy without the classic abdominal pain of pancreatitis, which contributed to diagnostic delay. He rapidly deteriorated into multiorgan failure and septic shock. Laboratory evaluation demonstrated markedly elevated lipase at 16 310 U/L, leucocytosis, metabolic acidosis, acute kidney injury and lactic acidosis. Serum triglycerides, calcium and glucose were within normal limits, excluding metabolic causes. Imaging confirmed necrotising pancreatitis with a large peripancreatic fluid collection. Following exclusion of alternative aetiologies, valproic acid was identified as the most likely cause. The patient improved with supportive management. This case underscores that valproic acid can cause life-threatening pancreatitis even at therapeutic levels and highlights the importance of reviewing medications, particularly in cases presenting atypically without abdominal pain.