We report a fatal case of anicteric leptospirosis with pancreatitis (acute hyperglycemia and insulin requirement, elevated lipase and amylase levels), pulmonary infiltrates, and refractory shock. In disease-endemic areas, leptospirosis with pancreatitis should be considered in patients with fever and abdominal pain, and serum pancreatic enzymes, blood glucose, and serum electrolytes should be closely monitored. Copyright © 2007 by The American Society of Tropical Medicine and Hygiene.