key: cord-0905796-a7t8smpc authors: Karimzadeh, Sedighe; Manzuri, Ali; Ebrahimi, Masoud; Huy, Nguyen Tien title: COVID-19 presenting as acute pancreatitis: Lessons from a patient in Iran date: 2020-06-08 journal: Pancreatology DOI: 10.1016/j.pan.2020.06.003 sha: 3bf5f015cc5180c764eb12a2412ae6817cc7f46e doc_id: 905796 cord_uid: a7t8smpc nan The pandemic of novel coronavirus (2019-nCoV) which originated in Wuhan, China in December 2019, has since spread worldwide. As of the eleventh of May 2020, a total of 4 million confirmed cases have been reported in more than 200 countries and territories [1] . We describe a patient with COVID-19 who presented with less common gastrointestinal symptoms of COVID-19 without early symptoms of respiratory complications. We report the challenges in early diagnosis of COVID-19 in this patient. A 65-year-old woman with underlying disease of hypertension and asthma presented to the emergency department. She complained of upper abdominal pain, constant nausea, chills, and myalgia for 5 days. The patient had been well until 5 days before the clinical presentation. She denied any history of contact or travel with patients with flu-like symptoms. On the first day she had chills and myalgia and was told she had a common viral illness after visiting a phycision in an outpatient clinic. The next two days, the symptoms increased in severity and upper abdominal pain developed. She presented again to other two outpatient clinics. In the clinic intravenous fluids were administered and she was discharged. She was advised to use Levofloxacin tabs and to return to the clinic if symptoms worsened or persisted. The next day, symptoms, particularly nausea, increased severely up to the point that the patient was unable to eat, or drink. The patient was visitied in her home by a physician. She was advised to refer to a hospital for further evaluation and with a probable diagnosis of gastrointestinal disease. On admission in the emergency department, the patient reported persistent nausea, chills, myalgia, and upper abdominal pain. She reported no shortness of breath or chest pain. Vital signs were within normal range. On physical examination, the patient was found to have dry mucous membrane, pallor, and mild tenderness on the right upper quadrant region of the abdomen. She also appeared fatigued. After admission, the patient received supportive care, intravenous fluid, and ondansetron for nausea. On day 2, during hospitalization, the patient reported mild shortness of breath and the vital signs remained stable. Chest computed tomography reveled bilateral subpleural patchy consolidation and ground glass opacities (Fig. 1 ). Covid-19 was diagnosed based on Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) testing and the (Table 1) . Other laboratory values were unremarkable. On day 4, the oxygen saturation decreased to 90% (in room air) and she reported exacerbated shortness of breath and nausea. The patient transported to the intensive care unit and was received supplemental oxygen by nasal cannula. On day 5, amylase increased to 285 U/L and lipase to 294 U/L. Chest computed tomography progressed to mild right pleural effusion, mild pericardial effusion, ground glass opacities, and diffused patchy consolidation. Abdominal computed tomography was reported to be normal. After intravenous and oral treatment with oseltamivir, hydroxychloroquine, ribavirin, lopinavir, ritonavir, vancomycin, cefepime, O2 therapy, and supportive therapy the patient was discharged with improved health condition after an 18-day hospitalization. The most common presentation and prevalent symptoms of Covid-19 are fever, cough and dyspnea. COVID-19 in a subset of patients may present with gastroenterological symptoms with or without respiratory symptoms. More common laboratory findings in Covid-19 patients with gastroenterological symptoms include elevated alanine aminotransferase and aspartate aminotransferase and they have been seen in up to 37% of cases [2, 3] . A pancreatic injury pattern is reported in 17% of 54 patients with COVID-19 in China [4] . Angiotensin-converting enzyme-2 (ACE-2) receptors are highly presented on the pancreas. Nonetheless, there is a paucity of evidence that binding of SARS-CoV-2 virus to ACE-2 receptors in the pancreas can cause injury to the islet of pancreas and elevation of serum amylase and lipase enzymes. Apart from elevated pancreatic enzymes, the imaging evaluation of pancreas in this patient shows no abnormalities or changes reported. Key aspects of this case included the less common presentation of COVID-19, the potential of mild pancreatic injury by Sars-CoV-2 virus, and a decision that was made by the patient to seek medical attention in different outpatient clinics. Misdiagnosis and recognition of the patient's clinical feature as a common viral illness due to the less common presentation of COVID-19 underline the significance of prompt isolation of suspected cases to reduce further transmission in the community. All authors contributed equally to this work. None. None. Coronavirus disease 2019 (COVID-19): situation report Clinical characteristics of coronavirus disease 2019 in China Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Pancreatic injury patterns in patients with COVID-19 pneumonia We would like to thank ICU staff at Vasei hospital for their support to this case report, and Dr Amr Khaled Hassan for proofreading of this manuscript.