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CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 427-430  

COVID-19-associated severe acute pancreatitis: A rare presentation


Medical Division, Command Hospital Air Force, Bengaluru, Karnataka, India

Date of Submission22-Aug-2020
Date of Decision26-Oct-2020
Date of Acceptance29-Oct-2020
Date of Web Publication29-Nov-2021

Correspondence Address:
Prashant Kumar Dixit
Command Hospital Air Force, Agram Post, Bengaluru - 560 007, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_469_20

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  Abstract 


As the knowledge about coronavirus disease 2019 (COVID-19) is increasing day by day, we are learning about various manifestations of COVID-19. The disease is a systemic illness that also involves the gastrointestinal system including the pancreas. Here, we report the case of a 14-year-old girl who presented with a pancreatic type of pain abdomen. She was diagnosed with acute pancreatitis (AP) based on clinical symptoms, ≥3 times the elevation of serum amylase, and imaging evidence of AP. Her Bedside Index of Severity in AP was 2/5 and the Modified Computed Tomography Severity Index was 10/10. She had positive reverse transcriptase-polymerase chain reaction for COVID-19. Her workup for common and rare causes of AP was negative. She was managed conservatively as per standard protocol for the management of AP. The aim of this case is to highlight the importance of causal association of COVID-19 with AP.

Keywords: Acute pancreatitis, amylase, coronavirus disease 2019, Computed Tomography Severity Index, severe acute respiratory syndrome coronavirus 2


How to cite this article:
Prasad AS, Mujeeb V R, Gupta S, Dixit PK. COVID-19-associated severe acute pancreatitis: A rare presentation. Med J DY Patil Vidyapeeth 2022;15:427-30

How to cite this URL:
Prasad AS, Mujeeb V R, Gupta S, Dixit PK. COVID-19-associated severe acute pancreatitis: A rare presentation. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:427-30. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/427/331498




  Introduction Top


Coronavirus disease 2019 (COVID-19) is caused by highly infectious severe acute respiratory syndrome coronavirus 2. It predominantly affects the respiratory system by gaining entry through angiotensin-converting enzyme receptor-2 (ACE-2) present in the lower respiratory tract.[1] It has also been reported to affect the gastrointestinal system by the same ACE-2 receptors which are expressed in the intestinal epithelium and pancreatic islet cells.[2],[3] There are few case reports on COVID-19-related acute pancreatitis (AP), but none has been reported from India.[4],[5] Here, we report a case of severe AP (SAP) associated with COVID-19 without symptomatic involvement of the respiratory system.


  Case Report Top


A 14-year-old girl with no known prior illness presented with complaints of pain abdomen and vomiting of 1-day duration. Pain abdomen was suggestive of pancreatic in origin with multiple episodes of nonbilious and nonprojectile vomiting. She also complained of obstipation and anorexia. There was no history of fever, cough, breathlessness, sore throat, running nose, chest pain, diarrhea, and oliguria. Initial examination revealed normal sensorium, temperature 98.2 F, pulse 116/min, blood pressure 112/72 mmHg, respiratory rate 30/min, SPO2 97% on room air, pallor, tenderness over the epigastric region with absent bowel sounds, and breath sounds over the left infra-axillary and infrascapular region. Her Bedside Index of Severity in AP was 2/5.

Hematology and laboratory investigation are shown in [Table 1]. Electrocardiogram was normal, and chest X-ray showed bilateral pleural effusion (left > right) and computed tomography (CT) of the chest confirmed the same. Ultrasound abdomen revealed a bulky body of the pancreas with acute necrotic collection around the tail and normal hepatobiliary system. Contrast-enhanced CT abdomen revealed acute necrotizing pancreatitis with splenic vein thrombosis and modified CT severity index 10/10 [Figure 1]. Her positive reverse transcriptase-polymerase chain reaction (RT-PCR) (nasopharyngeal swab) for SARS-CoV-2 was positive. A detailed etiological workup for AP was as follows: corrected calcium 10.07 mg/dl (8.5–10.5), triglycerides 49 mg/dl, negative HBsAg, anti-HCV, anti-hepatitis A/E virus IgM, serology for herpes simplex, coxsackievirus, human immunodeficiency virus, cytomegalovirus, and Epstein–Barr virus negative. Antinuclear antibody (ANA) by immunofluorescence with ANA profile by immunoblot assay was negative and IgG4 2.49 g/L (0.03–2.0).
Figure 1: Contrast-enhanced computed tomography abdomen showing partial thrombosis of the splenic vein (yellow arrow), necrosed body and tail of the pancreas (blue arrow), and normal enhancing head of the pancreas (green arrow)

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Table 1: Day-wise laboratory parameters

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On day 3 of admission, she developed fever, worsening of tachypnea, and desaturation requiring oxygen support. She was managed with bowel rest, intravenous fluids, low-molecular-weight heparin, ulinastatin (trypsin inhibitor), and supportive care. In view of poor oral intake, she was given total parenteral nutrition from day 6 to day 10 through the central line. She showed gradual improvement in clinical condition in the form of tolerance to oral feeds, resolution of tachycardia, tachypnea, defervescence, and no requirement of oxygen. Her total leukocyte count (TLC), procalcitonin, and inflammatory markers showed improvement. During her course of hospitalization, she did not develop pulmonary involvement due to COVID-19 as evidenced by the absence of ground-glass opacities or crazy-paving pattern on the CT chest. Her respiratory symptoms were a consequence of bilateral pleural effusion secondary to SAP. Her RT-PCR for COVID-19 after 10 days came as negative. Magnetic resonance cholangiopancreatography was done on day 17 revealed resolving acute necrotizing pancreas with 4.0 cm × 11.1 cm × 4.9 cm intrapancreatic fluid collection with the recanalized splenic vein, normal liver, gallbladder, and common bile duct. She was discharged in clinically stable condition on day 18. On further follow-up, she complained of occasional pain abdomen due to necrotic collection for 2–4 weeks. After 6 months of follow-up, she remained asymptomatic with no recurrence of symptoms.


  Discussion Top


We report the case of a teenage girl who presented with pancreatic-type pain abdomen and on evaluation found to have SAP. She was diagnosed with SAP based on clinical presentation, serum amylase more than three times the upper limit of normal, and imaging revealing features of AP. Her extensive workup for the common and rare causes of AP was negative. In view of RT-PCR for SARS-CoV-2 being positive, AP could be attributed to COVID-19 in our patient. Her respiratory system symptoms and signs were because of an increase in pleural effusion and not because of COVID-19. High TLC, CRP, and procalcitonin were due to systemic inflammatory response of AP and were unlikely to be due to secondary infection as we could not localize any source of infection.[6] Inflammatory marker elevation can also occur in severe COVID-19, so it is difficult to comment on whether this was due to SAP, COVID-19, or both. She was given LMWH which is indicated in SAP with splenic vein thrombosis as well as in severe COVID-19. Her serum IgG4 levels were slightly elevated, which can occur in type I autoimmune pancreatitis; however, it has greater association among aged >50 years, IgG4 ≥2 times, frequent biliary tract, and other extrapancreatic involvement.[7],[8] The absence of the above features in our case makes IgG4-related disease unlikely to be a cause of AP. Ulinastatin has been approved for the treatment of SAP which like tocilizumab inhibits the interleukin-6 and decreases cytokine storm and the severity of COVID-19.[9]

Common causes of AP are hepatobiliary stone disease, alcohol abuse, and metabolic causes, while infections including viral are responsible for up to 10% of AP.[10] Despite extensive evaluation, 10%–30% of all AP goes without the identification of etiology.[7] COVID-19 and pancreatic injury have been reported previously, notable among these was a study from China that revealed pancreatic injury defined as an elevation of amylase/lipase in 17% of COVID-19 patient.[11] Various authors have reported the association of AP with SARS-CoV-2; these patients developed mild to SAP after the involvement of the respiratory tract.[4],[5] Our case is unique because the patient presented with SAP without any clinical or imaging evidence of respiratory tract involvement.

As the disease is evolving, not much is known about the pathogenesis of AP due to SARS-CoV-2. It could be because of the direct cytopathic effect of the virus gaining entry through ACE-2 receptors present on pancreatic islet cells or immune-mediated injury to the pancreas and secondary activation of pancreatic enzymes.[3] Schepis et al. demonstrated the presence of a high quantity of SARS-CoV-2 from the sample obtained from a pancreatic pseudocyst.[12] The above study favors the direct cytopathic effect of the virus on pancreatic tissue and causal association of COVID-19 with AP.

The association of COVID-19 and the absence of alternative etiology in our case favors the causal association of SARS-CoV-2 with AP. Our case was unique since the patient presented with SAP without the involvement of the respiratory tract. Clinicians while dealing with AP should consider COVID-19 as a possible etiology. The presence of COVID-19 with AP brings out new challenges for the physician in the management of the case since both these conditions can cause overlapping features.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak An update on the status. Mil Med Res 2020;7:11.  Back to cited text no. 1
    
2.
Wong SH, Lui RN, Sung JJ. Covid-19 and the digestive system. J Gastroenterol hepatol 2020;35:744-8.  Back to cited text no. 2
    
3.
Patel KP, Patel PA, Vunnam RR, Hewlett AT, Jain R, Jing R, et al. Gastrointestinal, hepatobiliary, and pancreatic manifestations of COVID-19. Journal of Clinical Virology 2020;128:104386. (available online; doi.org/10.1016/j.jcv.2020.104386).  Back to cited text no. 3
    
4.
Hadi A, Werge M, Kristiansen KT, Pedersen UG, Karstensen JG, Novovic S, et al. Coronavirus disease-19 (COVID-19) associated with severe acute pancreatitis: Case report on three family members. Pancreatology 2020;20:665-7.  Back to cited text no. 4
    
5.
Meireles PA, Bessa F, Gaspar P, Parreira I, Silva VD, Mota C, et al. Acalculous acute pancreatitis in a COVID-19 patient. Eur J Case Rep Intern Med 2020;7:001710. (available online; doi:10.12890/2020_001710)  Back to cited text no. 5
    
6.
Liang Y, Zhao X, Meng F. Procalcitonin, C-reactive protein, and neutrophil ratio contribute to the diagnosis and prognosis of severe acute pancreatitis. Iran J Public Health 2019;48:2177-86.  Back to cited text no. 6
    
7.
Del Vecchio Blanco G, Gesuale C, Varanese M, Monteleone G, Paoluzi OA. Idiopathic acute pancreatitis: A review on etiology and diagnostic work-up. Clin J Gastroenterol 2019;12:511-24.  Back to cited text no. 7
    
8.
Chari ST, Takahashi N, Levy MJ, Smyrk TC, Clain JE, Pearson RK, et al. A diagnostic strategy to distinguish autoimmune pancreatitis from pancreatic cancer. Clin Gastroenterol Hepatol 2009;7:1097-103.  Back to cited text no. 8
    
9.
Zhao M. Cytokine storm and immunomodulatory therapy in COVID-19: Role of chloroquine and anti-IL-6 monoclonal antibodies. Int J Antimicrob Agents 2020;55:105982. (available online; doi: 10.1016/j.ijantimicag.2020.105982).  Back to cited text no. 9
    
10.
Rawla P, Bandaru SS, Vellipuram AR. Review of Infectious Etiology of Acute Pancreatitis. Gastroenterology Res 2017;10:153-8.  Back to cited text no. 10
    
11.
Wang F, Wang H, Fan J, Zhang Y, Wang H, Zhao Q. Pancreatic injury patterns in patients with coronavirus disease 19 pneumonia. Gastroenterology 2020;159:367-70.  Back to cited text no. 11
    
12.
Schepis T, Larghi A, Papa A, Miele L, Panzuto F, Biase LD, et al. SARS-CoV2 RNA detection in a pancreatic pseudocyst sample. Pancreatology 2020;20:1011-2.  Back to cited text no. 12
    


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