The patient was diagnosed with an unusual “terrible triad” of AP, HTG, and euglycemic DKA in the setting of canagliflozin and estrogen use and was admitted to the medical intensive care unit. The blue arrow indicates a small gallstone visualized in the gallbladder. The red arrow indicates the edematous pancreatic body and head with moderate surrounding peripancreatic inflammatory stranding and edema suggestive of acute pancreatitis. Her blood work showed the abnormalities listed in Table Table1 1. No abdominal distention or tenderness was noted, and Murphy’s sign was absent.

On physical examination, she appeared weak and lethargic with a dry tongue. On arrival at the hospital, she felt dizzy, and her vital signs were: blood pressure 103/50 mmHg, respiratory rate 36 per minute with Kussmaul’s respiration, heart rate 136 beats per minute, temperature 97.7☏, and body mass index 31.3 kg/m 2. She vaped marijuana occasionally and drank four alcoholic drinks per week.

She did not have any recent surgeries or gender-affirming surgery. She endorsed compliance with all her medications until her nausea set in two days prior. Her medications included oral estradiol 2 mg three times daily, finasteride 5 mg daily, spironolactone 50 mg twice daily, canagliflozin 300 mg daily, metformin 1,000 mg twice daily, atorvastatin 20 mg daily, and lamotrigine 100 mg daily. She denied prior abdominal pain related to fatty foods and did not drink alcohol before the episode. She denied any fevers, chills, dysuria, or diarrhea. She reported that the symptoms had started suddenly after she ate multiple cinnamon rolls and drank five glasses of milk, progressively worsening over two days. The abdominal pain was located in the epigastrium, 8/10 in intensity, radiating to the back, and with no aggravating or relieving factors. A 34-year-old transgender woman with a past medical history of type 2 diabetes, hyperlipidemia, and depression presented to the hospital with complaints of abdominal pain, poor appetite, and multiple episodes of nausea and vomiting for two days.

#TrueMessiahs by J.L. Gates