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.


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.
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.
The boy was treated with intravenous rehydration and fasting with nasogastric tube. The boy improved slowly and discharged with the diagnosis of idiopathic pancreatitis from hospital after one week in good condition, free of symptoms, and with normalization of laboratory tests. Three weeks later, the boy was readmitted to the hospital again with more severe similar clinical scenario, received the same palliative treatment, and discharged after two weeks with good condition. After 5 days he was readmitted again to the hospital with the same clinical presentation of severe pancreatitis. This admission lasted for one week and on discharge the family reported on the use of Ritalin and therefore it was recommended to stop taking Ritalin.   The boy is now free of symptoms for one year and half after stopping taking Ritalin.

Discussion
The use of Ritalin is noticeably increased worldwide in the last few years and is prescribed for several indications such as ADHD, behavior disorder, and even for improving scholar achievement [1].
The incidence of pediatric pancreatitis has increased significantly in the past two decades. It is estimated that 2 to 13 new cases occur annually per 100,000 children [2].
Pancreatitis affects a heterogeneous population of children, and symptoms range from mild to life threatening.
Unofficial data states that according to FDA reports published on the Internet in June 2013, 41 people of 8668 (0.47%) users of Ritalin in the United States declared to have pancreatitis within one month after starting the treatment. But we do not know if these 41 people have another underlying disease for developing pancreatitis.
We believe that the number of persons suffering from pancreatitis due to the use of Ritalin is more than this published case.
Physicians must pay attention regarding this possible complication and it should be taken into consideration in every patient with abdominal pain who started consuming Ritalin.
Because of clinical various degrees of presentation of pancreatitis, a lot of these patients are undiagnosed.

Conclusion
Acute pancreatitis in pediatric age could be due to the use of Ritalin. Because of increased use of this drug, physicians must be aware of this possibility and they must include this entity Case Reports in Gastrointestinal Medicine 3 in the differential diagnosis in every child suffering from abdominal pain and who was also recently started to take this medicine. We suggest further investigation in this issue.