|Year : 2022 | Volume
| Issue : 2 | Page : 200-203
COVID-19-Induced acute pancreatitis – A case series
Bal Mukund1, Amit Kumar2, Vivek Bhat1, DK Tiwari1, RW Thergaonkar1
1 Department of Pediatrics, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Medicine, INHS Asvini, Mumbai, Maharashtra, India
|Date of Submission||07-Mar-2022|
|Date of Decision||11-Mar-2022|
|Date of Acceptance||12-Mar-2022|
|Date of Web Publication||10-Aug-2022|
Surg Capt Bal Mukund
Sr Adv- Pediatrics and Intensive Care, INHS Asvini, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
The present pandemic of the COVID-19 virus has caused enormous morbidity and mortality to humankind. Acute pancreatitis (AP) in otherwise healthy patients infected with the COVID-19 virus has been reported only as case reports and series. We report a series of three cases of AP including one adolescent with necrotizing pancreatitis due to COVID-19 infection, out of total 4117 COVID-19 admission (0.07%) in our hospital till February 8, 2022. Detailed investigations for etiological diagnosis of AP were within normal limits thus, the causation was attributed to COVID-19 viral infection as causative agent. One child succumbed to the illness as he also manifested with features of multisystem inflammatory syndrome and had progressive multi-organ dysfunction despite aggressive management. Further studies are required before a clear mechanism of causation due to the COVID-19 virus is proven in AP.
Keywords: Acute pancreatitis, angiotensin-converting enzyme 2 receptor, COVID-19, modified computerized tomography severity score, severe acute respiratory syndrome coronavirus 2
|How to cite this article:|
Mukund B, Kumar A, Bhat V, Tiwari D K, Thergaonkar R W. COVID-19-Induced acute pancreatitis – A case series. J Mar Med Soc 2022;24:200-3
COVID-19-induced pancreatitis has been sparingly reported in literature, even rarer- acute necrotizing pancreatitis has not been reported from Indian subcontinent. We report three cases of acute pancreatitis in COVID-19 infection including one acute necrotizing pancreatitis where other causes of acute pancreatitis were not found, however, most of them can be managed supportively.
The present pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged from Wuhan, China, and has caused 39.8 crores cases and approximately 57.7 lakhs death until February 8, 2022. Previous research described acute pancreatitis (AP) in 8.5%–17% of patients with COVID-19; however, these studies did not emphasize clinical features and imaging findings which are crucial for diagnosis of AP according to the revised Atlanta classification., Gastrointestinal involvement is increasingly being recognized. COVID-19 as viral cause of asymptomatic pancreatic disease is being reported; however, symptomatic cases are extremely rare. These are large families of single-stranded RNA viruses whose pathogenesis is dependent on angiotensin-converting enzyme 2 (ACE-2) receptor which is abundantly present in esophageal epithelial cells, enterocytes in ileum and colon, and in pancreas, especially in ductal and acinar cells and islets., We report three cases of AP [Table 1] due to SARS-CoV-2 out of total of 4117 admitted cases since this pandemic outbreak in our hospital.
|Table 1: Patients profile of coronavirus disease-2019 with acute pancreatitis|
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Case 1 had shown self-limiting AP which was resolved with conservative treatment. Case 2 showed acute necrotizing pancreatitis which has rarely been reported in the literature due to COVID-19 and improved with supportive treatment. Our third patient had signs of multi-organ dysfunction syndrome (MODS) at presentation with 24-h PRISM III was 12 and showed rapid deterioration despite aggressive treatment with immunomodulation, mechanical ventilation, and all supportive treatment. We could not do computerized tomography (CT) as the child deteriorated within 6 h of admission requiring escalation of respiratory support from HHFNC to mechanical ventilation and inotropes infusion. Despite aggressive treatment, the child succumbed to MODS at 34 h of admission. We evaluated for all possible causes of AP but could not demonstrate any except COVID-19 infection by polymerase chain reaction/truant/serology. We did not do chest CT as there were no respiratory complaints in case 1 and case 2, hence CORAD scores are not available.
| Discussion|| |
The most prevalent symptoms of COVID-19 in the present pandemic have been of respiratory system; however, gastrointestinal symptoms such as nausea, vomiting, loose stools, and abdominal pain have been reported, especially in children and adolescents., Even in COVID-19 pneumonia from China depicted high amylase in 17% of patients and also pancreatic injury. We documented three cases of AP among 4117 COVID admissions (0.07%); however, we did not look for asymptomatic raised amylase/lipase levels. It clearly shows that frank AP is very rare in COVID-19 and its bearing in clinical course is still to be elucidated.
A clear pathogenesis is unknown; however, pancreatic injury has been postulated to occur as a part of systemic inflammatory response or direct cytopathic effect of SARS-CoV-2 replication which has been postulated to occur due to abundant ACE-2 receptors in pancreas. Bulthuis et al. in their study of AP with COVID-19 infections postulated AP as a result of transient hypoperfusion and pancreatic ischemia rather than as a part of systemic inflammatory response. Since ACE-2 receptors are abundant in islets, a transient acute diabetes has also been mentioned. None of our AP patients had dysglycemia. Viral RNA of COVID-19 virus has also been detected in fluid of pseudocyst of patients in COVID pneumonia with edematous pancreas. Many of the COVID-19 patients do receive antipyretics and steroids which may also contribute to drug-related pancreatic injury. We gave steroids to only one patient with COVID-19 with MODS (case 3). Children and adults with COVID-19 with AP have worse pancreatitis severity, length of stay, intensive care unit admission, organ failure, and mortality compared to AP without COVID-19., Pediatric patients with COVID-19 have probably higher chance of necrosis than adult patients. One of our patients had pancreatic necrosis; however, most of the case reports and series from adult population did not document necrotizing pancreatitis associated with COVID-19. In the international survey of 22 patients from 20 countries in pediatric COVID-19 with AP, 2 patients had features of necrosis and 3 patients had pseudocyst formation. The same study found higher incidence of AP in female gender than male 2;1; however, all of our patients were male which might have been due to admission bias in a service hospital. Incidence of MODS including acute kidney injury (AKI) was 45%; however, only one of our patients had features of AKI and MODS. All of our patients had high D-dimer and C-reactive protein as was evident in this international survey (92% and 935, respectively). Feldstein et al. reported on characteristics and outcomes of US children with multisystem inflammatory syndrome in children (MIS-C) versus children with severe acute COVID-19 infection. From their cohort of 539 children with MIS-C and 577 children with severe acute COVID-19, they reported a 2.4-fold increase in pancreatitis in the MIS-C group (17 versus 7), respectively, than otherwise. We had one adolescent who had features of MISC who later succumbed to MODS.
|Figure 2: (a) Focal nonenhancing area tail of pancreas with 30% necrotization. (b) Mesenteric fat stranding. (c) Bilateral pleural effusion|
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All our patients had clinical symptoms, laboratory values (>3 times serum amylase/lipase), and radiological evidence (two patients having CT proven and one patient having ultrasound features) of AP thus satisfying all criteria for revised Atlanta classification. One of our patients had features of acute necrotizing pancreatitis. This adolescent also had incidental findings of ansa pancreatica on follow-up magnetic resonance cholangiopancreaticogram. This anomaly has been found as a predisposing factor for AP and probably the COVID-19 infection in this patient precipitated the acute necrotizing pancreatitis. Our study is probably only one from India, a case series of COVID-19-induced AP which was managed supportively. Since none of our patients showed any other etiological factor hence we assumed it to be due to COVID-19 virus as has been reported by others. One of our patients had necrotizing features of AP on CT scan though he recovered from the illness. We intend to follow both these patients in future. Our study is not without limitations such as being retrospective in nature, also we did not screen all COVID patients for AP; hence we might have missed milder cases or asymptomatic cases of AP as has been shown in study from China. We also could not prove viral RNA in pancreatic fluid/duodenal fluid which would have ideal to prove the direct cytopathic viral effect. In conclusion, AP in COVID-19 is rare though they may require more intensive monitoring and supportive treatment may be enough in majority. A large prospective multi centric study can elucidate further in this co-occurrence vis etiology. Further large studies are also required to elucidate precipitating factors for AP in COVID-19 patients.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
et al. Classification of acute pancreatitis – 2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013;
Bulthuis MC, Boxhoorn L, Beudel M, Elbers PW, Kop MP, van Wanrooij RL, et al.
Acute pancreatitis in COVID-19 patients: True risk? Scand J Gastroenterol 2021;56:585-7.
Rana SS. Clinical Manifestations of COVID-19 involving the gastrointestinal tract. J Postgrad Med Edu Res 2020;54:112-4.
Liu F, Long X, Zhang B, Zhang W, Chen X, Zhang Z. ACE2 expression in pancreas may cause pancreatic damage after SARS-CoV-2 infection. Clin Gastroenterol Hepatol 2020;18:2128-30.e2.
Adukia SA, Ruhatiya RS, Maheshwarappa HM, Manjunath RB, Jain GN. Extrapulmonary features of COVID-19: A concise review. Indian J Crit Care Med 2020;24:575-80.
He JX, et al.
Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.
Schepis T, Larghi A, Papa A, Miele L, Panzuto F, De Biase L, et al.
SARS-CoV2 RNA detection in a pancreatic pseudocyst sample. Pancreatology 2020;20:1011-2.
Pandanaboyana S, Moir J, Leeds JS, Oppong K, Kanwar A, Marzouk A, et al.
SARS-CoV-2 infection in acute pancreatitis increases disease severity and 30-day mortality: COVID PAN collaborative study. Gut 2021;70:1061-9.
Slae M, Wilschanski M, Sanjines E, Abu-El-Haija M, Sellers ZM. International survey on severe acute respiratory syndrome coronavirus 2 and acute pancreatitis co-occurrence in children. Pancreas 2021;50:1305-9.
Feldstein LR, Tenforde MW, Friedman KG, Newhams M, Rose EB, Dapul H, et al.
Characteristics and outcomes of US children and adolescents with Multisystem Inflammatory Syndrome in Children (MIS-C) compared with severe acute COVID-19. JAMA 2021;325:1074-87.
Jarrar MS, Khenissi A, Ghrissi R, Hamila F, Letaief R. Ansa pancreatica: An anatomic variation and a rare cause of acute pancreatitis. Surg Radiol Anat 2013;35:745-8.
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