Letter to the Editor
Acute necro-hemorrhagic pancreatitis during SARS-CoV-2 infection
Pancreatitis aguda necrohemorrágica durante la infección por SARS-CoV-2
María José Arche Banzo
, Almudena Matute Guerrero, Sandra Herrero García
Corresponding author
Servicio de Medicina Intensiva, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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She went to the emergency department after presenting with progressive dyspnoea. With a diagnosis of bilateral pneumonia, she was admitted to the ward and received treatment with dexamethasone and remdesivir. The patient's breathing worsened, and she was admitted to the Intensive Care Unit (ICU), where orotracheal intubation was performed and prone-supine manoeuvres were started. In addition, hyperimmune plasma and tocilizumab were added to the treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">After an initially good respiratory progression, on the 12th° day of admission to the ICU the patient experienced a distributive <span class="elsevierStyleItalic">shock</span>. On examination, she had abdominal distension, absence of peristalsis and a feeling of fullness in the epigastrium. An emergency computed tomography (CT) scan was performed, which showed the presence of pneumoperitoneum and changes suggestive of acute pancreatitis in the pancreatic uncinate process. Amylase and lipase levels were normal (37 IU/L and 42 IU/L, respectively). An emergency exploratory laparotomy was performed and necro-haemorrhagic pancreatitis in an advanced stage of development was confirmed. During the following hours, the patient developed progressive haemodynamic instability and multi-organ failure. Finally, she passed away 12 h later.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Infectious pancreatitis is a rare entity, caused mainly by hepatotropic viruses, mumps virus, cytomegalovirus (CMV), coxsackie B, human immunodeficiency virus (HIV), varicella zoster virus (VZV) and, less frequently, influenza A.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Acute pancreatitis in COVID-19 patients has been rarely reported. Our patient presented bilateral pneumonia with acute respiratory distress syndrome (ARDS) (PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> < 200) and concomitant acute necro-haemorrhagic pancreatitis. The diagnosis of pancreatitis was based on imaging tests and direct visualization through exploratory laparotomy. The usual aetiologies of acute pancreatitis were ruled out.</p><p id="par0035" class="elsevierStylePara elsevierViewall">SARS-CoV-2 is introduced into host cells through binding of its peak protein (S) to angiotensin-converting enzyme 2 (ACE2), expressed on the surface of cells in multiple sites.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The pathophysiology of gastrointestinal damage in COVID-19 is probably multifactorial: direct virus-mediated tissue damage is plausible, given the presence of ACE2 in glandular cells of the digestive system,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> also, the histopathological evidence of diffuse inflammation and mesenteric ischemia suggest the existence of lesions in the microvascularization of the digestive tract.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding pancreatic injury, ACE2 expression in pancreatic cells may be slightly higher than in respiratory epithelial cells, both in exocrine regions and in endocrine pancreatic islets.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Detection of SARS-CoV-2 RNA in a pancreatic pseudocyst fluid sample in a patient with SARS-CoV-2 pneumonia and acute pancreatitis has even been reported.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Cases of acute pancreatic injury have been reported in COVID-19 patients, among others, the study published by Liu et al., reported that 17.9% and 16.4% of patients had increased levels of amylase and lipase, respectively, and only 7.46% showed pancreatic changes on computed tomography (CT).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The temporal association between acute pancreatitis and COVID-19 is strongly indicative of SARS-CoV-2-induced injury. Our patient received treatment with remdesivir and tocilizumab, of which no adverse effects related to severe acute pancreatitis have been described so far in the SmPC, as well as high-dose corticosteroid therapy. The possibility of attributing some causality to drugs should not be underestimated. The presence of pneumoperitoneum on CT raised the diagnostic hypothesis of complicated diverticulitis, a clinical entity described in patients who have received treatment with tocilizumab. It was finally ruled out by exploratory laparotomy. The origin of the pneumoperitoneum was not found. The possible presence of anaerobic, gas-producing microorganisms was considered, but this was not confirmed because intraoperative cultures were not obtained.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Most reported cases have been diagnosed within a moderate or severe disease process, suggesting that the pathophysiology of pancreatitis could be based on a systemic inflammatory response rather than a direct cytopathological effect caused by SARS-CoV-2.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">This article has not received any type of funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 3 => array:2 [ "identificador" => "xack599507" "titulo" => "Acknowledgement" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arche Banzo MJ, Matute Guerrero A, Herrero García S, Pancreatitis aguda necrohemorrágica durante la infección por SARS-CoV-2. Med Clin (Barc). 2022;158:346–347.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COVID-19 research consortium. prevalence, risk factors, and outcomes of hospitalized patients with coronavirus disease 2019 presenting as acute pancreatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Inamdar" 1 => "P.C. Benias" 2 => "Y. Liu" 3 => "D.V. Sejpal" 4 => "S.K. Satapathy" 5 => "A.J. 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Li" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cgh.2020.04.040" "Revista" => array:5 [ "tituloSerie" => "Clin Gastroenterol Hepatol" "fecha" => "2020" "volumen" => "18" "paginaInicial" => "2128" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32334082" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.K. Yang" 1 => "S.S. Lin" 2 => "X.J. Ji" 3 => "L.M. Guo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00592-009-0109-4" "Revista" => array:6 [ "tituloSerie" => "Acta Diabetol" "fecha" => "2010" "volumen" => "47" "paginaInicial" => "193" "paginaFinal" => "199" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19333547" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack599507" "titulo" => "Acknowledgement" "texto" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Special thanks to Dr. Nuria Sánchez Donoso.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015800000007/v1_202205040609/S2387020622001152/v1_202205040609/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/23870206/0000015800000007/v1_202205040609/S2387020622001152/v1_202205040609/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622001152?idApp=UINPBA00004N" ]
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