Acute Pancreatitis in a COVID-19 Patient in Brazil

A Case Report

Caroline Petersen da Costa Ferreira; Kalynne Rodrigues Marques; Gustavo Henrique Ferreira de Mattos; Tércio de Campos

Disclosures

J Med Case Reports. 2021;15(541) 

In This Article

Discussion

The group of coronaviruses (CoV) is a group of single-stranded ribonucleic acid (RNA) viruses, belonging to the subfamily Orthocoronavirinae and family Coronaviridae, which infect humans and animals. Only the alpha and beta genera can infect humans, with symptoms often associated with a cold.[3] The first epidemic caused by CoV occurred in 2002 in Guangdon, China, by SARS-CoV-1 causing severe acute respiratory syndrome (SARS) with 916 deaths in 29 countries. Then, in 2012, Middle East respiratory syndrome (MERS) caused by a CoV was identified with 858 deaths. In 2019, there were reports of symptomatic individuals who had contact with SARS-CoV-2 present in bats from a wet market in Wuhan, China, being responsible for COVID-19. In the three episodes, there was zoonotic overflow, aggravated by the cultural practices and fragile health laws in those regions.[4,5]

Classical symptoms include fever, cough, and fatigue in addition to sputum, hemoptysis, diarrhea, headache, and lymphopenia. Unique features include targeting of the lower airways and RNAemia, combined with incidence of ground-glass opacity and acute cardiac injury.[6]

AP is a disease caused by an abnormality in the activation of pancreatic enzymes with the release of inflammatory mediators, which can compromise peripancreatic tissues and other organs.[7] AP has a multitude of potential causes, including gallstones, alcohol, hypertriglyceridemia, trauma, post-endoscopic retrograde cholangiopancreatography (ERCP), hypercalcemia, medications, anatomic anomalies, and infections or toxins. Known viral causes of pancreatitis include mumps, coxsackievirus, hepatitis B, cytomegalovirus, varicella zoster, herpes simplex, and human immunodeficiency virus.[8]

Up to 10% of AP is thought to have an infectious etiology through an immune-mediated inflammatory response, most notably mumps and coxsackie B viruses.[9] However, the pathophysiological mechanism by which a virus, such as the coronavirus, could cause acute pancreatitis is not clear. The main explanations suggest a cytopathic effect of viral replication, or the virus-induced immune response itself.[10] In this patient, other causes of AP were excluded (including alcohol, biliary obstruction/gallstones, anatomic anomalies, drugs, trauma, hypertriglyceridemia, hypercalcemia, and hypotension).

This case demonstrates the possibility of pancreatic injury in patients with COVID-19, in line with previously reported similar cases. A literature review was performed in April 2020 with the following descriptors: acute pancreatitis and COVID-19 in PubMed database, and eight cases were found: two cases in the same family,[11] one case in a pregnant woman,[12] one in a child,[13] one in a woman in Iran,[14] one in a woman in Paris,[15] one in a woman in the UK,[16] and one in a man in Romania.[17] Among these eight cases, only one case occurred in an adult man,[17] as in the case described in this report.

A new literature review was carried out in May 2021 with the following descriptors: acute pancreatitis and COVID-19 in PubMed database, and about 90 papers showed up. Of these, 54 were case or series reports. One study shows the point prevalence, risk factors, and outcomes of 32 hospitalized patients with COVID-19 presenting with acute pancreatitis in a large health system and compares outcomes of pancreatitis in patients without COVID-19.[18] Another one analyzed the clinical profiles of 17 patients with COVID-19 and acute pancreatitis.[19] Most of the other studies were about the increase of amylase and lipase without pancreatitis or about the possible relationships between these two entities. Further large studies are needed to confirm these findings. A better understanding of the relationship between AP and COVID-19 will guide clinicians on early management strategies and focus medical resources toward those patients at risk for worse outcomes.

The increased interest in studying the relationship between AP and COVID-19 suggests a yet to be delineated complex interaction between them.

It is important to note that patients infected with COVID-19 can present the less common gastrointestinal symptoms without early respiratory symptoms. This highlights the need for appropriate personal protective equipment for providers, even when COVID-19 is not initially on the differential diagnosis.

processing....