key: cord-0859113-3ig5tc36
authors: Ashok, Aditya; Faghih, Mayha; Singh, Vikesh K.
title: Mild Pancreatic Enzyme Elevations in COVID-19 Pneumonia: Synonymous with Injury or Noise?
date: 2020-06-13
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.05.086
sha: 1fde8d6b5b846ecd74e11c6a5ab37627d1e0f3c3
doc_id: 859113
cord_uid: 3ig5tc36

nan

We read the article 1 by Dr. Wang and colleagues with interest. They suggest that pancreatic enzyme elevations signify pancreatic injury due to cytotoxic effects of the SARS-CoV-2 virus.

While preliminary data 2 suggests that the transmembrane protease serine 2 (TMPRSS2) and angiotensin-converting enzyme 2 (ACE2), which mediate cellular entry of SARS-CoV-2, are found on pancreatic ductal cells, the pathologic consequences of this are not clear at the current time. The use of serum pancreatic enzyme elevations to delineate the presence or degree of pancreatic injury is not validated or recommended, for example, in asymptomatic patients for monitoring of checkpoint inhibitor induced pancreatic toxicity 3 or for determining the degree of pancreatic injury in trauma patients 4 .

The clinical significance of serum amylase and lipase elevations primarily centers on their role in diagnosing acute pancreatitis. In the absence of imaging, none of the 9 patients in this series met the revised Atlanta classification criteria for acute pancreatitis as there was no report of abdominal pain and the pancreatic enzymes were not above 3 times the upper limit of normal.

Serum lipase is widely recommended over amylase for diagnosing acute pancreatitis because of its improved sensitivity. Therefore, any potential clinical merits of this study lie primarily in those five patients (cases 1, 4, 5, 8 and 9) with elevated lipase levels. However, lipase can be elevated without obvious major clinical sequelae for a variety of reasons not related to direct cytotoxic effects of SARS-CoV-2 including ICU critical illness (case 4), diabetes (cases 1 and 5), and opioid use (not detailed) [5] [6] [7] . Of the five cases of mildly elevated lipase, only two (cases 8 and 9) do not have obvious alternative explanations as delineated above, and the lipases in those cases are 85 and 77 U/L [upper limit of normal (ULN) was 70 U/L], respectively. This could be within the margin of error for the laboratory assay. Our own laboratory, for example, has a serum lipase ULN of 63 U/L with a 10% margin of error (personal communication); therefore, the application of this margin of error to case 9 would bring their lipase into the normal range. We would also point out that seven of the nine patients received corticosteroids (cases 1, 3, 4, 5, 6, 7, 8) which has been associated with elevated lipase levels 8 .

In summary, the majority of these patients in the study by Wang 

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