Acute pancreatitis in a COVID-19 positive patient

A 32-year-old male presented to the emergency department of AIIMS Rishikesh with chief complaint of epigastric pain since 7 days, radiating to back and associated with vomiting. No history of fever/jaundice was there. No history of alcoholism/ trauma/ medication intake was present. The patient underwent nasal and oropharyngeal swab for SARS-CoV-2 RT-PCR which was positive.

On presentation, the patient underwent the investigations listed in figure 6. CECT abdomen was done which revealedbulky pancreas in body and tail region measuring ~ 31mm and 23mm in thickness with irregular outline. Diffuse peripancreatic fat stranding was seen with peripherally enhancing peripancreatic collections and collection in lesser sac. Splenic vein thrombosis was seen for a segment of ~ 11mm near its confluence with superior mesenteric vein. CT severity index was 6/10. The scanned lung fields revealed left minimal pleural effusion with passive atelectasis. No interstitial thickening was seen. No peripheral ground glass opacity was identified. CT lung window did not show features of covid pneumonia.

The patient underwent ultrasonography which did not reveal any presence of calculi in gall bladder. He was treated symptomatically with fluid replacement and empirical antibiotics. Follow up investigations were done and patient was discharged after an uneventful recovery.

COVID- 19 most commonly manifests as respiratory symptoms, however gastrointestinal manifestations of the disease have been reported such as lack of appetite, vomiting, diarrhoea.[1] Pancraetic injury is a part of this spectrum of gastrointestinal findings. Several conditions can lead to pancreatitis. Out of these alcohol abuse and gall stone disease are major risk factors. [2]

Based on patient’s history and clinical examintaion, suspicion of acute pancreatitis was made. The diagnosis of acute pancreatitis depends usually on the clinical parameters; however, pancreatic enzymes can be raised in a number of other gastrointestinal conditions. Therefore, imaging plays an important role in aiding the diagnosis, detecting possible causes, complications, and to assess disease severity based on imaging scoring systems. Imaging findings corroborated the diagnosis.

In view of lack of typical risk factors, coupled with the time of onset of symptoms and the positive RT-PCR test, a causal relationship between the disease and COVID- 19 was established.

The pathophysiology of COVID – 19 virus leading to acute pancreatitis is not yet known, however it could either be attributed to the direct cytopathic effect of virus on the pancreatic cells or indirect injury might occur from the host immune response to the virus.[3,4]  A study by Furong Liu et al. shows that ACE2 expression in islet cells of pancreas can explain pancreatic damage caused by the virus. Spike protein of the virus binds to the ACE2, hence ACE2 acts as a receptor for viral entry into the cell. [5]

The patient did not have any respiratory complaints. He was maintaining an oxygen saturation of 96% on room air. Only a few cases have been reported where a COVID positive patient presented with acute pancreatitis without any pulmonary symptoms. [6,7]

The knowledge of possible association between COVID-19 virus and acute pancreatitis can help in early diagnosis and eventual management of the patient.