Norethindrone acetate/ethinyl estradiol (Estrostep; Warner Chilcott, Rockaway, New Jersey) is an "estrophasic" type of oral contraceptive, which combines a continuous low progestin dose with a gradually increasing estrogen dose. In clinical trials, this medication failed to produce clinically significant changes in serum lipid levels. We report a case of severe hypertriglyceridemia-induced acute pancreatitis in a 24-year-old woman caused by Estrostep, occurring nearly 10 years after she began using the drug. The patient was admitted to the medical intensive care unit (ICU) for aggressive volume resuscitation and management of severe electrolyte abnormalities. Laboratory studies obtained on admission indicated severe hypertriglyceridemia (2,200 mg/dL), hyponatremia (120 mEq/L), and hypocalcemia (0.78 mmol/L). Amylase and lipase levels were also elevated (193 and 200 U/L, respectively). Ranson score calculated after 48 hours of admission was 4, and her Acute Physiology and Chronic Health Evaluation (APACHE) IV score was 35. Treatment included an insulin infusion, ω-3 fatty acid esters, and gemfibrozil. The insulin infusion reduced serum triglyceride levels by 50% after 1 day of treatment and to 355 mg/dL by day 7 of her ICU course. We believe that this is the first reported case of severe, acute hypertriglyceridemia-induced pancreatitis caused by this medication.

cardiac rhythm abnormalities are common, and mostly include sinus tachycardia or occasionally bradycardia. Rarely, lethal rhythm abnormalities like ventricular tachycardia, prolonged QT abnormalities, or asystole can occur leading to serious consequences including sudden unexplained death in epilepsy (SUDEP). New evidence indicates that possible mechanisms may include a sudden catecholamine surge and simultaneous sympathetic and parasympathetic (sympathovagal) discharge. We postulate that the combination of sympathovagal imbalance resulting from both the seizures and the marijuana abuse might have lead to an additive effect, which in the presence of ictal or post-tachycardia might have triggered the AF. Additionally, factors such as vomiting, hypoxia, hypercapnia, acidosis, and electrolytes abnormalities, which are commonly seen during GTCC, are proarrhythmogenic and have been implicated in causing AF. We think that, these factors are less likely responsible for the initiation of AF in our patient, as arterial blood gas and serum electrolytes were completely normal during initial evaluation in emergency department. Severe hemodynamic compromise leading to hypoxemic ischemic injury to the brain and ischemic stroke due to thromboembolic phenomenon secondary to atrial dilatation may also lead to seizures but in our case these two possibilities were ruled out by imaging and normal echocardiographic studies. Conclusion: We suggest seizures and marijuana abuse should be considered in the differential diagnosis of the etiology of AF. We recommend close monitoring of cardiac function in these patients.