Acute pancreatitis in a patient with COVID-19 infection

Dear Editor,

Since the first cases of the SARS-CoV-2 coronavirus infection appeared in the city of Wuhan, the disease has taken on pandemic characteristics. 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.

Although the severity of the infection is mainly determined by the development of severe pneumonia and acute respiratory distress, other conditions have been described in different organs and systems. Vomiting, diarrhoea and abdominal pain are common digestive system-related symptoms.¹ Liver involvement is also common.² We report a case of acute pancreatitis that could be related to COVID-19 infection.

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 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 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 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.

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.² Nor do we believe that omeprazole intake is the cause, since although cases³ 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.

COVID-19-related pancreatic involvement has been described in the form of high amylase and lipase levels.⁴ This involvement is pathophysiologically consistent, as the pancreas expresses the angiotensin-converting enzyme, whose receptors facilitate the penetration of the virus.⁴ One case of acute pancreatitis attributable to COVID-19 infection has been described,⁵ 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.³