key: cord-0967411-otjhzr6q
authors: Bokhari, Syed Muhammad Mashhood Ali; Mahmood, Fatima
title: Case Report: Novel Coronavirus—A Potential Cause of Acute Pancreatitis?
date: 2020-07-08
journal: Am J Trop Med Hyg
DOI: 10.4269/ajtmh.20-0568
sha: b2bbf4c642787559046d1b88a1fb2fe15c953b7b
doc_id: 967411
cord_uid: otjhzr6q

A 32-year-old medical practitioner presented to the emergency department with complaints of severe abdominal pain, fever, and vomiting, 1 week after the diagnosis of COVID-19. The patient did not report any comorbid conditions, alcohol usage, or gallstone disease. Laboratory and radiological investigations revealed the diagnosis of acute pancreatitis. He underwent conservative management and was discharged after 3 days of hospital admission. This case highlights a possible association between COVID-19 and acute pancreatitis, and the need for clinicians to carefully evaluate patients presenting with gastrointestinal complaints during the current pandemic.

A 32-year-old male patient presented to the outpatient clinic at Nishtar Hospital, Multan, Pakistan, with a history of relapsing fever, sore throat, productive cough, myalgia, and diarrhea for 1 week. The patient was a medical physician currently working in the medicine ward. He did not report any prior comorbidities or high-risk travel history.

Considering the exposure history, a reverse transcriptase-PCR for COVID-19 was obtained. Initially, the patient's temperature was 38°C, the blood pressure 110/80 mmHg, the pulse rate 110 beats per minute, the respiratory rate 16 breaths per minutes, and oxygen saturation 99-100% while breathing in ambient air. He was managed with simple supportive measures.

After 21 hours, his tests for COVID-19 were reported positive. The patient chose to self-isolate at home until his symptoms subsided and his results came negative. He was advised to report to the emergency department in case of severe dyspnea, chest pain, cyanosis, or altered mental status.

A week after the diagnosis, the patient reported to the emergency department with severe mid-epigastric pain radiating to the back accompanied by intermittent high fevers, chills, and non-biliary vomiting. He was noted to have a white cell count of 12 × 10 9 /L and glucose levels of 192 mg/dL. Liver function tests revealed aspartate aminotransferase of 29 IU/L and alanine aminotransferase of 27 IU/L. Kidney functions were normal, serum triglycerides were 150 mg/dL, and serum calcium was 8.9 mg/dL. Serum amylase was 672 IU/L and serum lipase 721 IU/L ( Table 1 ). The patient reported no history of use of alcohol.

Ultrasound in the emergency ward showed no signs of inflammation of the gall bladder or cholelithiasis. Computed axial tomography scan of the abdomen revealed a bulky and swollen pancreas with significant peripancreatic inflammatory changes and fluid collection along the gastrosplenic ligament. Otherwise, the pancreas was non-enhancing, with no evidence of low-attenuation areas in the pancreatic parenchyma to suggest necrosis ( Figure 1 ).

Considering a diagnosis of acute pancreatitis, the patient was kept nothing per oral and on intravenous fluids, analgesics, antibiotics, and antiemetics. The patient's intake and output were monitored, and he was gradually mobilized from bed. Alongside, incentive spirometry and chest physiotherapy were initiated.

Over the next 3 days, his lipase was constantly monitored and showed a downward trend, 380, 198, and 56 IU/L. On day 3, his symptoms improved, and he was started on clear fluids and soft diet through oral route, which was successfully tolerated. The patient was discharged home without any sequelae.

In early December 2019, Wuhan City, China, experienced a sudden outbreak of pneumonia. Investigation led to isolation of a novel coronavirus as the cause of outbreak. The WHO named it as COVID-19 on February 11, 2020. This virulent pathogen rapidly spread in China and other regions in the world. Till date, the virus continues to cause a devastating pandemic worldwide, threatening global health and affecting approximately 4,000,000 people. It causes great threats to the growth of economy and society. 1, 2 Respiratory symptoms such as cough, shortness of breath, and sore throat appear to be the pathognomonic signs in a patient infected with the coronavirus; however, the literature 3 In our case, the diagnosis of pancreatitis in this patient appears to be idiopathic in the absence of comorbid conditions, cholelithiasis, alcohol usage, trauma, or recent invasive procedures such as endoscopic retrograde cholangiopancreatography. However, around 10% of cases are due to miscellaneous factors such as viral, bacterial, or parasitic infections. Notably, Coxsackievirus, herpes simplex virus, mumps, human immunodeficiency virus, and Mycoplasma, among several others, are responsible for causing infectious pancreatitis. 4 Similar cases have been reported recently from Newport (United Kingdom) and Denmark, where multiple patients with COVID-19 disease presented with complaints of acute pancreatitis. 5, 6 A study in Wuhan city showed the prevalence of pancreatic injury in nine of 52 patients admitted in a hospital. It suggested that the pancreatic injury could be due to heavy expression of angiotensin converting enzyme or harmful systemic immune response induced by COVID-19 infection. 7 Based on this case and the aforementioned studies, we recommend further studies to be conducted to evaluate any possible association between COVID-19 and acute pancreatitis. CONCLUSION This is a case describing the incidence of pancreatitis in a COVID-19-positive patient. We encourage medical practitioners to carefully evaluate gastrointestinal symptoms and measure serum amylase and lipase levels in patients presenting with abdominal pain and COVID-19.

The novel coronavirus originating in Wuhan, China: challenges for global health governance

The SARS-CoV-2 outbreak: diagnosis, infection prevention, and public perception moderators

Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China

Review of infectious etiology of acute pancreatitis

Acute pancreatitis in a COVID-19 patient

Coronavirus Disease-19 (COVID-19) associated with severe acute pancreatitis: case report on three family members

Pancreatic injury patterns in patients with COVID-19 pneumonia

FIGURE 1. CT scan showing a swollen pancreas with inflammatory changes in surrounding areas. NOVEL CORONAVIRUS-A POTENTIAL CAUSE OF ACUTE PANCREATITIS?

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