Letter to the Editor
Acute pancreatitis in a patient with COVID-19 infection
Pancreatitis aguda en paciente con infección por COVID-19
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In Spain, according to the 14th May 2020 update from the Ministry of Health, there have been 228,540 cases, with a total of 27,321 deaths.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the severity of the infection is mainly determined by the development of severe pneumonia and acute respiratory <span class="elsevierStyleItalic">distress</span>, other conditions have been described in different organs and systems. Vomiting, diarrhoea and abdominal pain are common digestive system-related symptoms.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Liver involvement is also common.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> We report a case of acute pancreatitis that could be related to COVID-19 infection.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 76 year-old woman, ex-smoker, with low-risk alcohol consumption (10 g of pure alcohol, one day a week). Personal history of hypercholesterolemia and gastroesophageal reflux. Chronic omeprazole treatment (20<span class="elsevierStyleHsp" style=""></span>mg/day) for more than 10 years, which took on demand. Twenty-four days before hospital admission, the patient had taken three 500 mg tablets of azithromycin for acute sinusitis. She came to the hospital for an 8 h-history of epigastric pain, radiated to both hypochondriac regions, accompanied by vomiting. Approached as possible acute pancreatitis, it was confirmed by high levels of plasma amylase (3568<span class="elsevierStyleHsp" style=""></span>IU/L) and compatible abdominal ultrasound, without cholelithiasis. The rest of the laboratory parameters were normal, except for a slight increase of neutrophils (84%) and C-reactive protein (1.9<span class="elsevierStyleHsp" style=""></span>mg/dL). An abdominal CT confirmed the diagnosis and classified it as interstitial oedematous pancreatitis. A subsequent CT and magnetic resonance cholangiography showed similar findings and again ruled out biliary pathology. The PCR was positive for COVID-19, with symptoms of fever and diarrhoea. A chest X-ray was normal. Treatment with hydroxychloroquine, azithromycin, and lopinavir plus ritonavir was started, with a good response. Similarly, regarding the pancreatitis, the patient progressed favourably under conservative treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We believe that the absence of at-risk alcohol consumption and calculous disease, the main causes of acute pancreatitis, point to a possible infectious cause of COVID-19. We do not believe that the history of taking azithromycin more than 3 weeks before is related to pancreatitis, which was not made worse by the reintroduction of azithromycin treatment. In this sense, a possible case of azithromycin-induced pancreatitis has been described in our setting, although the authors themselves stated that it was a difficult-to-demonstrate relationship.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Nor do we believe that omeprazole intake is the cause, since although cases<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> have been described, it is unlikely after 10 years of exposure. Both with azithromycin and omeprazole, the attribution of causality is doubtful with the Naranjo algorithm.</p><p id="par0025" class="elsevierStylePara elsevierViewall">COVID-19-related pancreatic involvement has been described in the form of high amylase and lipase levels.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> This involvement is pathophysiologically consistent, as the pancreas expresses the angiotensin-converting enzyme, whose receptors facilitate the penetration of the virus.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> One case of acute pancreatitis attributable to COVID-19 infection has been described,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> with compatible symptoms and CT scans, although no laboratory tests were available to demonstrate high levels of amylase. The patient had been diagnosed with COVID-19 infection and had received treatment with vancomycin and tetracycline, showing the symptoms compatible with acute pancreatitis 5 days after discharge. The latter antibiotic has also been linked to the development of acute pancreatitis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gonzalo-Voltas A, Uxia Fernández-Pérez-Torres C, Baena-Díez JM. Pancreatitis aguda en paciente con infección por COVID-19. Med Clin (Barc). 2020;155:183–184.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Covid-19 and the digestive system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.H. Wong" 1 => "R.N. Lui" 2 => "J.J. Sung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jgh.15047" "Revista" => array:6 [ "tituloSerie" => "J Gastroenterol Hepatol" "fecha" => "2020" "volumen" => "35" "paginaInicial" => "744" "paginaFinal" => "748" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32215956" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Drug-induced acute pancreatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.L. Ruiz Rebollo" 1 => "C. Tafur Sánchez" 2 => "M. Martín Asenjo" 3 => "Udaondo CascanteMA" 4 => "J.M. González Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gastrohep.2015.11.008" "Revista" => array:6 [ "tituloSerie" => "Gastroenterol Hepatol" "fecha" => "2016" "volumen" => "39" "paginaInicial" => "424" "paginaFinal" => "425" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26839206" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Drug-induced acute pancreatitis: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.R. Jones" 1 => "O.M. Hall" 2 => "A.M. Kaye" 3 => "A.D. Kaye" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ochsner J" "fecha" => "2015" "volumen" => "15" "paginaInicial" => "45" "paginaFinal" => "51" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Covid-19-related pancreatic injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Mukherjee" 1 => "A. Smith" 2 => "R. Sutton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/bjs.11645" "Revista" => array:5 [ "tituloSerie" => "Br J Surg" "fecha" => "2020" "volumen" => "107" "paginaInicial" => "e190" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32352160" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute pancreatitis in a COVID-19 patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.R. Anand" 1 => "C. Major" 2 => "O. Pickering" 3 => "M. Nelson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/bjs.11657" "Revista" => array:5 [ "tituloSerie" => "Br J Surg" "fecha" => "2020" "volumen" => "107" "paginaInicial" => "e182" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32339257" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015500000004/v2_202008242222/S2387020620303260/v2_202008242222/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015500000004/v2_202008242222/S2387020620303260/v2_202008242222/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620303260?idApp=UINPBA00004N" ]
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