Acute Pancreatitis in a Patient with COVID-19: A Case Report

The global pandemic of the infectious disease coronavirus 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a predominantly respiratory disease. Gastrointestinal symptoms occur in 15-20% of patients with COVID-19, however, there have not been many case reports of acute pancreatitis in patients with COVID-19. We presented the case of a 28-year-old girl suffering from COVID-19 with acute pancreatitis in the absence of other known etiological risk factors for pancreatitis. Laboratory analysis revealed a marked elevation of lipase and amylase. CT of the abdomen showed an edematous pancreas with diffuse enlargement. She was diagnosed with acute pancreatitis due to COVID-19 after carefully ruling out other causes. She was managed symptomatically, and improvement in her clinical condition was observed and was discharged with outpatient follow-up. ABSTRACT


Introduction
A new disease, COVID-19 caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has caused a global health crisis, a pandemic, with more than 581.3 million cases worldwide and over 6.4 million deaths [1].
The transmission of respiratory pathogens have been associated with three primary modes known as "contact," "droplet," and "airborne" transmission. The contact transmission can occur directly by physical touch or indirectly via fomites containing settled droplets [2]. COVID-19 is well described as a respiratory disease, but recent studies have shown that an increasing number of patients report gastrointestinal manifestations such as diarrhea, nausea, vomiting, and abdominal pain [3]. Despite the fact that knowledge about this virus is added daily, the impact of COVID-19 on the pancreas is still less researched. We presented a patient with COVID-19 who had acute pancreatitis without respiratory symptoms.

Case Presentation
It was about a 28-year-old woman, who was admitted to the clinic for infectious diseases of the University Clinical Center of the Republika Srpska Banja Luka. Three days before admission, she felt a headache, a high temperature, which lasted for one day, epigastric pain with propagation to the back, as well as nausea and vomiting.
Comorbidities were excluded, except for obesity [Body Mass Index (BMI): 31.1]. He has an allergy to pollen from before, does not consume alcohol, smokes, uses up to 10 cigarettes a day. He works as an administrative technician. She had surgery The global pandemic of the infectious disease coronavirus 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a predominantly respiratory disease. Gastrointestinal symptoms occur in 15-20% of patients with COVID-19, however, there have not been many case reports of acute pancreatitis in patients with COVID-19. We presented the case of a 28-year-old girl suffering from COVID-19 with acute pancreatitis in the absence of other known etiological risk factors for pancreatitis. Laboratory analysis revealed a marked elevation of lipase and amylase. CT of the abdomen showed an edematous pancreas with diffuse enlargement. She was diagnosed with acute pancreatitis due to COVID-19 after carefully ruling out other causes. She was managed symptomatically, and improvement in her clinical condition was observed and was discharged with outpatient follow-up.
ABSTRACT on her eyelids, was treated for depression a few years ago, used clomipramine tablets, and does not take medication at the time of symptoms. There were no health problems in the family. Upon admission, a Polymerase Chain Reaction (PCR) test was performed, which confi rmed the infection with COVID-19. On admission, the patient had a temperature of 37.6C, pulse rate of 78 beats per minute, normal blood pressure (125/70mmHg), no signs of dehydration, anicteric and Oxygen Saturation (SaO2) of 98% on room air. Diff use abdominal pain and pronounced epigastric pain during abdominal palpation were recorded. There were no other fi ndings in the physical and neurological examination. Levels of alpha amylase, lipase, pancreatic amylase and C reactive protein were elevated on admission. Laboratory analyzes are presented in table 1.
A computerized tomography of the Chest and abdomen (CT) is performed. Computed tomography of the chest showed in the lung parenchyma in the postero-and laterobasal segments bilateral minor zones of GGO (eng. Ground-glass opacity) as part of the COVID-19 infection. On the pleura, thickenings in both lower lobes of no more than 5 mm can be seen as part of scar changes. The heart is not enlarged. There is no fl uid in the pericardium. There are no pathological lymphatics in the mediastinum. Conclusion: Co-RADS 5A, early stage disease.
Computed tomography of the abdomen with contrast describes, in conclusion: 1. Enlarged and heterodense head of the pancreas and the uncinate process, most likely in support of acute pancreatitis, but another etiology cannot be ruled out. 2. Intestinal pneumatosis in the wall of the duodenal gyrus accompanied by free fl uid around the duodenal ring. 3.
On admission, antibiotics are included therapeutically, empirically, for possible upgraded bacterial pneumonia.
The patient was kept on a diet for acute pancreatitis, with continuous intravenous fl uid replacement, proton pump inhibitors, preventive doses of anticoagulant therapy with broad-spectrum antibiotics.
During hospitalization, she had no respiratory signs or symptoms, nor did she need oxygen supplementation.

Discussion
The spike glycoprotein of the SARS-CoV-2 virus binds to the Angiotensin-Converting Enzyme 2 (ACE2) receptor on human cells, which enables the entry of SARS-CoV-2 into the target cell [4]. ACE2 receptors are present on the surface of respiratory tract cells, lung alveoli, heart, blood vessels, liver, kidney, digestive tract, exocrine pancreas and islet cells [4,5]. This is exactly why COVID-19 has such a diverse symptomatology that diff ers from other to 17% of active cases of COVID-19 [8]. Pancreatic enzymes such as amylase and lipase can be secreted by organs other than the pancreas such as the lungs. Amylases required for starch digestion are mainly secreted by the pancreas and salivary glands, but other organs including normal and diseased lungs [9]. Lipase, which in adults is mainly secreted by the pancreas, is the key enzyme for digesting triglycerides. Lipase is also excreted by the kidneys [9,10].
Also, high serum amylase and lipase activity is reported in conditions such as severe gastroenteritis, diabetes, post-cardiovascular surgery, trauma, burns, and kidney damage due to renal clearance of pancreatic enzymes [10].
Since our patient did not have burns, trauma or surgery, elevated values of amylase and lipase were interpreted as a direct eff ect of SARS-COV2 on the gastrointestinal tract.
An important fact is that the activity and replication of the virus in the intestines can last even after the virus has been cleared from the respiratory tract [10]. Pancreatitis can be a consequence of direct viral invasion, or secondary to hypoxic eff ects or damage mediated by cytokines, the exact mechanism is diffi cult to assume at this time [10].
Also, high serum amylase and lipase activity is reported in conditions such as severe gastroenteritis, diabetes, post-cardiovascular surgery, trauma, burns, and kidney damage due to renal clearance of pancreatic enzymes [10].
Since our patient did not have burns, trauma or surgery, elevated values of amylase and lipase were interpreted as a direct eff ect of SARS-COV2 on the gastrointestinal tract.
An important fact is that the activity and replication of the virus in the intestines can last even after the virus has been cleared from the respiratory tract [10].
Pancreatitis can be a consequence of direct viral invasion, or secondary to hypoxic eff ects or damage mediated by cytokines, the exact mechanism is diffi cult to assume at this time [3,10]. and two of eight (25%) cases of focal pancreatitis with hemorrhagic and necrotic changes of the pancreas were found. These changes had no clinical manifestations and were attributed to ischemia and organ damage [12]. The exact pathophysiology of pancreatic damage remains unclear, while the most accepted hypothesis points to pancreatic ischemia [13]. If septicemia progresses to septic shock, not only with COVID-19, but also with other infections, the resulting hypotension and vasodilation reduce blood fl ow to organs. To protect blood fl ow to vital organs such as the brain and heart, blood fl ow to the intestines, superior and inferior mesenteric arteries is reduced as part of a protective mechanism. This is a neurohormonal mechanism that protects vital organs. Amylase, lipase, aspartate aminotransferase and lactate dehydrogenase are released into the bloodstream due to ischemia resulting from reduced blood fl ow in the pancreas [13]. This damage is mainly caused by hemodynamic deterioration and not by the virus itself.

Conclusion
Although acute pancreatitis is rare in patients with COVID-19, it should be considered in patients with severe epigastric pain and respiratory symptoms, even in mild cases of COVID-19. These patients should be followed up to assess the patient's recovery and/or associated complications, including new-onset diabetes, chronic pancreatitis. The pathophysiological mechanism of increased levels of amylase and lipase in patients positive for COVID-19 seems to have a multifactorial pathogenesis. Additional studies are needed to clarify the causal relationship between SARS-CoV-2 and acute pancreatitis.