key: cord-0922101-2f8r37ns
authors: Bonney, Glenn Kunnath; Yujia, Gao; Chew, Claire Alexandra; Windsor, John Albert
title: SARS-COV-2 associated acute pancreatitis: Cause, consequence or epiphenomenon?
date: 2020-05-29
journal: Pancreatology
DOI: 10.1016/j.pan.2020.05.019
sha: e1f93c0aa869435106692e85e71777207ff4b983
doc_id: 922101
cord_uid: 2f8r37ns

nan

The rapid spread of a novel coronavirus disease (COVID-19) caused by the severe acute respiratory coronavirus 2 (SARS-CoV-2) has triggered a global pandemic. With most patients presenting with respiratory symptoms, there is a relative paucity of knowledge about the impact of COVID-19 on the gastrointestinal tract. In the early phases of the pandemic, there appeared to be no known link between the SARS-CoV-2 virus and the pancreas.

Since then, however, there have been several reports of acute pancreatitis (AP) in COVID-19 patients.

Wang et al. were the first to describe this in a case series of 52 patients, 9 of whom were diagnosed with AP. [1] Another study found elevated amylase and lipase levels in 12 of 64 patients with severe COVID-19 infection. [2] The severity of AP observed varies from mild [1, 2] to severe,[43 but unfortunately accepted diagnostic criteria [4] was not used in these studies, raising the possibility that the elevated pancreatic enzymes may be due to other causes including increased gut permeability with SARS-CoV-2 infection. Not only is there uncertainty about the incidence of SARS-CoV-2 associated AP but there are also questions about its clinical features and pathogenesis. We do not know the timing of AP in relation to SARS-CoV-2 inoculation or the natural history and clinical trajectory of SARS-CoV-2 associated AP. It is not known whether currently accepted prognostic scoring systems for AP are appropriate, whether there is a heightened proinflammatory response, or whether the risk of organ dysfunction (especially acute respiratory distress syndrome) is compounded and/or more severe. When available, it will be interesting to study the impact of future vaccines and novel therapeutics designed for SARS-CoV-2 on the clinical course of AP.

Acute pancreatitis associated with viral infections, most commonly the hepatitis B virus and Coxsackie B virus, is well described. [7] The mechanism by which AP develops following viral infections varies depending on the 3 type of virus involved. [7] SARS-CoV-2 is known to enter cells by binding to the receptor proteins ACE2 and TMPRSS2. A study from 2010 using immunostaining found ACE2 to be highly expressed in islet cells and postulated that binding of SARS-CoV caused islet cell injury and hyperglycaemia in infected patients. [8] Single-cell RNA sequencing has been used to evaluate their expression, but there is conflicting data with one study reporting high expression within ductal and acinar cells, [3] while another study found no significant expression in the pancreas. [9] It is not known whether SARS-CoV-2 causes AP, whether the AP is a consequence of severe systemic inflammation and microvascular thrombosis from COVID-19 infection, or whether it is just an epiphenomenon.

More data about SARS-CoV-2 associated AP is needed from both the laboratory and the clinic. One way forward might be to use a pancreas organoid model to study the pancreas-specific effects of SARS-CoV-2, analogous to the intestinal organoid model used to study enteric infections. [10] There is also an urgent need for more international collaboration to pool clinical and scientific experience about SARS-CoV-2 associated AP, to better understand it and to improve the management of these patients.

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ACE2 Expression in Pancreas May Cause Pancreatic Damage After SARS-CoV-2 Infection

Coronavirus Disease-19 (COVID-19) associated with severe acute pancreatitis: Case report on three family members

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Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes

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The authors have no conflicts of interest or financial support to declare.