#Faezeh Sehatpour

[jcrmhscasereports]

Case of Necrotizing Pancreatitis following COVID-19 Infection by Faezeh Sehatpour in Journal of Clinical Case Reports Medical Images and Health Sciences  

ABSTRACT

New aspects of COVID-19 are increasingly being recognized. Although the virus is mainly known to affect the lungs, involvement of other organs including the heart, liver, gastrointestinal, renal and pancreas is also detected. Acute pancreatitis is detected as one of both the early and late presentations of COVID -19. Cytokine storm or the presence of angiotensin-converting enzyme 2 (ACE2) receptor in pancreatic cells, are both two causes of pancreatic injury in COVID-19 infection. In this study, we reported a 25-year-old man admitted to our department with the impression of necrotizing pancreatitis concomitant with COVID-19 infection. Patient's lab data, imaging and outcomes were documented in full detail.

Abbreviations:

WBC, white blood cell;HB, hemoglobin; MCV, mean corpuscular volume; PLT, platelet; BUN, blood urea nitrogen; Na, sodium; K, potassium; ; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ALK.P, alkaline phosphatase; ALB, albumin; LDH, Lactate dehydrogenase ; CPK, creatine phosphokinase; CRP,c-reactive protein; AFP,alpha-fetoprotein; CEA,carcinoembryonic antigen; CA19-9,cancer antigen 19-9; Immunoglobulin G4.

INTRODUCTION

The Covid-19 pandemic is an ongoing pandemic that started in December 2019 and spread rapidly around the word. COVID-19 was caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), first identified in Wuhan, China. So far, more than 200 countries have been affected by the pandemic. (1)

New aspects of COVID-19 are increasingly being recognized. Although the virus is mainly known to affect the lungs, involvement of other organs including the heart, liver, gastrointestinal, renal and pancreas is increasingly being reported. (2)

The involvement of the gastrointestinal system is maybe due to the expression of the angiotensin-converting enzyme2 (ACE2) on the hepatocyte, cholangiocyte and  other parts of the GI tract. (3) In a recent survey, acute pancreatitis was detected as one of both early and late presentations of COVID -19. (4-6) However, it is still unclear whether SARS-COV-2 directly affects pancreatic cells because of ACE2, if it is a cytokine storm which causes pancreatic injury. (7)

We reported a case of COVID-19 with subsequent acute necrotizing pancreatitis.

CASE REPORT

A 25-year-old man without any known medical disease presented to our emergency department with progressive epigastric pain, nausea and vomiting and anorexia one week prior to admission. He has no history of alcohol consumption. He also had a history of admission to another hospital about two weeks ago with a diagnosis of COVID-19 pneumonia. On admission, he has a blood pressure of 115/75 mm HG, a heart rate of 100 beats per minute, a temperature of 37.1 ⁰C and oxygen saturation of 95% while the patient is breathing in the room air. Primary investigations summarized in Table-1. Amylase and lipase were 146 IU/L and 82 IU/L respectively. Nasal swab test for COVID-19 (RT-PCR for SARS-CoV-2) was positive. Abdominal sonography showed markedly prominent pancreas with in homogeneous parenchymal echogenicity and large cystic lesion arising from the pancreas, in favor of acute complicated pancreatitis with pseudo cyst. The gall bladder has a normal size and wall thickness without any gall stones. The pancreatic duct was not dilated.  Due to the finding of abdominal ultra sound, CT scan of abdomen was done on him which revealed an enlarged pancreas with necrosis of the main portion of pancreatic parenchyma. Large cystic lesion measuring 15×7×11 cm in size arising from the pancreatic neck with extension to the right and left side of the abdomen suggestive of large pancreatic pseudo cyst (figure1).  Lung HRCT (low dose) also showed bilateral peripheral ground glass opacities in favor of COVID-19 pneumonia (figure2). According to the findings of a physical exam, laboratory data and clues in imaging immediate management of acute necrotizing pancreatitis (invasive intravenous hydration and pain control) was started for him. He was finally discharged from the hospital with a full recovery.

Table 1: laboratory data

Figure 1: Abdominal CT scan:  large loculated pseudo cystic structure measuring about 158mm*100mm in lesser sac due to post pancreatitis pseudo cyst formation.

Figure 2: lung HRCT: multiple ground glass and bilateral pleural effusion

DISCUSSION

Acute pancreatitis is an acute inflammation of the pancreas characterized by abdominal pain, nausea, vomiting and elevated exocrine pancreatic enzymes; amylase and lipase. Gallstones and chronic alcohol abuse are the most common causes of acute pancreatitis. Viruses are uncommon causes of acute pancreatitis. Pancreatitis has been reported with several viruses, including mumps, coxsackievirus, hepatitis A and B virus, cytomegalovirus, varicella-zoster, herpes simplex and human immunodeficiency virus. (8)

Although we have not conclusively proven the presence of the virus in the pancreas, the causes of COVID-19 and acute pancreatitis and the lack of other clear causes for pancreatitis strengthen the relationship between the two diseases.  In this study, the patient presented with necrotizing COVID-19in 19 in the early post period of COVID-19 infection.

In Fan Wang and colleagues' survey, 52 COVID-19 cases followed and showed that 17% of COVID-19 patients developed pancreatic injury and presented with mild elevated pancreatic enzymes; serum amylase and lipase without clinically severe pancreatitis. The possibility of drug induced acute pancreatitis in patients who have received medication due to COVID-19 is also expressed as one of the reasons for acute pancreatitis in COVID-for19 infection. (9) Saffa Saeed Al Mazrouei and his teammates reported a 24-year-old patient with acute non-necrotizing pancreatitis with concurrent COVID-19. No evidence of pseudo cyst or abscess was detected in his imaging. (10)

Pancreatic damage can be due to the direct effect of the virus on pancreatic cells or indirectly secondary to the immune system. In another study in Wuhan, it showed that ACE2 was expressed in the pancreas higher than the lung in the normal population, indicating that SARS-CoV-2 can bind to ACE2 in the pancreas and cause pancreatic cell damage. (7, 11)

Acute pancreatitis is one of the presentations or complications of COVID-19 infection. Further investigation with samples is needed to reveal the pathophysiology, presentation, treatment and prognosis of acute pancreatitis in COVID-19 infection.

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