key: cord-1046460-hzjm6sit
authors: Sudarsanam, Hemanth; Ethiraj, Dillibabu; Govarthanan, Navaneetha Kumar; Kalyanasundaram, Srinivasan; Chitra, Sathya Arunachalam; Mohan, Saisurendar
title: COVID-19 Associated Acute Necrotizing Pancreatitis with Normal Serum Amylase and Lipase Levels: Report of an Unusual Finding
date: 2021-09-30
journal: Oman Med J
DOI: 10.5001/omj.2021.129
sha: d21afefc3b7b962966989bbf9506ccaf8350dc6e
doc_id: 1046460
cord_uid: hzjm6sit

Coronaviruses are a large family of single-stranded RNA viruses infecting humans and animals, causing a multitude of symptoms. COVID-19 is not only known to affect the respiratory system, but shows unusual gastrointestinal complications. Pancreatitis can be caused by biliary stones, alcohol abuse, viruses, drug intake, metabolic syndromes, or trauma. Diagnosis of acute pancreatitis requires any two of the three criteria: acute onset of severe upper abdominal pain, consistent with pancreatitis; elevation of serum amylase or lipase, three times the upper limit of normal; and/or characteristic imaging findings. COVID-19 associated pancreatitis is thought to be mediated by the angiotensin-converting enzyme-2 receptor on the host cells, which are highly expressed in the pancreatic cells. Here, we report a unique case of acute necrotizing pancreatitis caused by COVID-19 with hyperglycemia and normal amylase and lipase levels.

C oronaviruses are a family of singlestranded RNA viruses causing infections in animals and humans. 1 COVID-19 is caused by novel coronavirus SARS-CoV-2. Since the onset of the COVID-19 pandemic, a wide spectrum of gastrointestinal complications and few cases of acute pancreatitis have been reported in association with COVID-19 infection. 1 Here, we report a unique case of acute necrotizing pancreatitis caused by COVID-19 with hyperglycemia and normal amylase and lipase levels.

A 35-year-old male presented to the emergency department with complaints of abdominal pain, fever, and mild cough lasting for five days. He was not an alcoholic and had no history of trauma, chronic disease, or medication use. On examination, he was febrile with tenderness in the epigastric region, and oxygen saturation was maintained. Laboratory investigations revealed normal serum amylase (46 U/L; units per liter) and lipase levels (42 U/L). His gamma-glutamyl transferase levels were elevated (149 U/L), and liver function tests were normal. Random blood glucose was elevated (240 mg/dL), and serum calcium (9 mg/dL) and lipid profile (triglycerides: 130 mg/dL) were normal. The patient was subjected to abdominal contrast-enhanced computed tomography (CECT), which showed non-enhancing necrotic areas involving the tail of the pancreas with fluid and fat stranding in the peripancreatic spaces and thickening of the adjacent fascial planes. The rest of the pancreas was unremarkable. Bilateral minimal pleural effusion was noted. A diagnosis of acute necrotizing pancreatitis was given on imaging (modified CT severity index: 8/10) [ Figure 1 ]. No cholelithiasis or choledocholithiasis was seen on CT. The visualized base of lungs showed groundglass opacities and interstitial septal thickening. The patient underwent a dedicated chest CT, which revealed bilateral confluent and discrete, subpleural and peribronchovascular consolidations with ground glass opacities [ Figure 2 ]. Given the typical imaging findings for COVID-19, the patient underwent reverse transcription polymerase chain reaction (RT-PCR) for COVID-19, which was positive. Initially, he was treated conservatively with bowel rest, analgesics, intravenous fluid resuscitation, and empirical antibiotics. Serum amylase and lipase levels were repeated the next day and remained within

Coronaviruses are a large family of single-stranded RNA viruses infecting humans and animals, causing a multitude of symptoms. COVID-19 is not only known to affect the respiratory system, but shows unusual gastrointestinal complications. Pancreatitis can be caused by biliary stones, alcohol abuse, viruses, drug intake, metabolic syndromes, or trauma. Diagnosis of acute pancreatitis requires any two of the three criteria: acute onset of severe upper abdominal pain, consistent with pancreatitis; elevation of serum amylase or lipase, three times the upper limit of normal; and/or characteristic imaging findings. COVID-19 associated pancreatitis is thought to be mediated by the angiotensin-converting enzyme-2 receptor on the host cells, which are highly expressed in the pancreatic cells. Here, we report a unique case of acute necrotizing pancreatitis caused by COVID-19 with hyperglycemia and normal amylase and lipase levels. normal limits. The patient's symptoms gradually improved, and he was discharged.

Acute pancreatitis is caused by various etiologies, including gallstones, alcohol abuse, hypertriglyceridemia, hypercalcemia, iatrogenic causes, infections, autoimmune and hereditary conditions, chronic medications, and trauma. 2 A wide range of bacterial, viral, fungal, and parasitic organisms can cause pancreatitis. Mumps, coxsackie, measles, and Hepatitis viruses have been implicated in causing pancreatitis. 3 The diagnosis of acute pancreatitis requires any two of the following three criteria: acute onset of severe upper abdominal pain, consistent with pancreatitis; elevation of serum amylase or lipase, three times the upper limit of normal; and characteristic imaging findings. 4 CECT abdomen has very high sensitivity and specificity of 90% for diagnosis of pancreatitis. 5 Revised Atlanta classification categorizes acute pancreatitis into interstitial edematous and necrotizing pancreatitis based on imaging findings. Acute necrotizing pancreatitis typically occurs by 48-72 hours after the disease onset. 6 Our patient had typical abdominal pain, and imaging showed pancreatic necrosis with peripancreatic inflammation and collection leading us to the diagnosis of acute necrotizing pancreatitis. A study states that CT is less sensitive in picking the necrosis before four days of onset. 7 CECT is generally recommended after 4-5 days of onset when the necrosis starts to appear radiologically. 8 Our case had mild non-enhancing necrotic areas only in the tail region. So, we presumed that CT was showing an early phase of necrosis. Chest CT revealed ground-glass opacities and consolidation, which were proven to be secondary to COVID-19 by RT-PCR. Our patient had no history of alcohol intake, trauma, medications, or any prior interventions, with Since CT chest findings and RT-PCR confirmed COVID-19, we ascertain that acute necrotizing pancreatitis was also caused by COVID-19 infection. COVID-19 pancreatitis is thought to be mediated by angiotensin-converting enzyme-2 (ACE-2) receptors on the host cells, which are highly expressed in the pancreatic cells. 9 Possible pathogenesis include the direct cytopathic effect of local viral replication or by the immune response induced by the virus indirectly. Our case had a unique finding that serum amylase and lipase levels were not elevated, both at admission and the next day. Serum amylase has low specificity and can be elevated in various conditions like cholecystitis and also be normal in alcohol and hypertriglyceridemia induced pancreatitis. 10 Lipase is produced and stored in pancreatic acinar cells; hence, it is very specific and has a negative predictive value of 94-100% in diagnosing pancreatitis. 11 The literature shows that lipase levels increase within 4-8 hours of acute pancreatitis onset to peak at 24 hours. Amylase levels rise after 6-24 hours and peak at 48 hours. These enzymes stay elevated in the bloodstream for about 7-14 days. However, it was peculiar to note the normal enzyme levels despite the ongoing infective and inflammatory processes in our case. 12 Many isolated case reports have documented that acute pancreatitis can have normal lipase levels. 4, 5, 10, 11 In acute or chronic pancreatitis cases, both amylase and lipase levels may remain normal due to loss of secretory function after chronic inflammation and fibrosis of the gland. In the case series of COVID-19 associated pancreatitis published by Wang et al, 13 three patients had elevated amylase but normal lipase levels. To the best of our knowledge, this is the first case of COVID-19 pancreatitis with normal lipase and amylase levels.

Another finding in our case was hyperglycemia. Hyperglycemia in a COVID-19 patient with pancreatitis could be due to the direct cytopathic effect of the virus, as the islet cells are more concentrated in the pancreatic tail region and show high expression of the ACE-2 receptors. 14 Other possible reasons for hyperglycemia include stress-induced transient hyperglycemia and incidentally detected pre-existing diabetes. 15 Diabetes workup including glycated hemoglobin assay may be useful in ascertaining the cause of hyperglycemia. Identifying the COVID-19 patients with pancreatitis is of paramount importance as they usually have a severe illness on admission and multisystem involvement with an accelerated clinical course. Including the upper abdomen in CT chest plain study for COVID-19 pneumonia also helps in the early identification of pancreatitis. CECT plays an important role in confirming the diagnosis and identification of necrosis, assessing severity, and initiating appropriate treatment.

COVID-19 patients can present as acute pancreatitis with normal serum amylase and lipase levels. Emergency physicians should be aware of this diagnostic conundrum, have a high index of suspicion in patients presenting with acute abdominal pain during this pandemic, and set a low threshold for further evaluation with imaging.

Acute pancreatitis: diagnosis, prognosis and treatment

Evaluation and management of acute pancreatitis

Review of infectious etiology of acute pancreatitis

Acute pancreatitis with normal amylase and lipase-an ED dilemma

Normal lipase serum level in acute pancreatitis: a case report

Necrotizing pancreatitis: diagnosis, imaging, and intervention

Practice and yield of early CT scan in acute pancreatitis: a Dutch observational multicenter study

Pancreatic necrosis: complications and changing trend of treatment

COVID-19 induced acute pancreatitis: a case report and literature review

Acute pancreatitis with normal serum lipase and amylase: a rare presentation

Acute pancreatitis with normal serum lipase: a case series

A critical evaluation of serum lipase and amylase as diagnostic tests for acute pancreatitis

Pancreatic injury patterns in patients with coronavirus disease 19 pneumonia. Gastroenterolog

Regional differences in islet distribution in the human pancreas-preferential beta-cell loss in the head region in patients with type 2 diabetes

Current evidence on pancreatic involvement in SARS-CoV-2 infection

The authors declared no conflicts of interest. r efer ences