S1454 Severe Acute Pancreatitis Initial Presentation of COVID-19 Infection

Abstract

INTRODUCTION: SARS-CoV-2, also known as the COVID-19 has affected more than 7 million people worldwide. While the most scommon initial symptoms are cough and fever, it is known that approximately 50% of patients present with GI related symptoms. We discuss below a case of a COVID-19 patient who initially presented with unexplained severe acute pancreatitis (AP). CASE DESCRIPTION/METHODS: A 71-year-old male presented to the hospital with significant abdominal pain for one day. In the ER, a contrast enhanced CT scan showed peripancreatic inflammation and peripancreatic fluid along the body and tail. The initial lipase was 8400 u/L (73–393 u/L). The patient had no alcohol history or evidence of biliary obstruction. He denied acetaminophen, steroids, or any new medications. The lipid panel was normal along with the LFTs. The BISAP score on admission was 3 for: age >60, BUN >25, and SIRS criteria of fever and leukocytosis. He was treated for severe acute pancreatitis with aggressive IV fluid hydration. On day 4, he had resolution of his abdominal pain and was tolerating a full liquid diet. Despite improvement in his severe acute pancreatitis, the patient developed persistent fevers and increasing oxygenation requirements. A chest X-Ray was then performed with showed infiltrates concerning for pneumonia. He tested positive for COVID-19 and then developed progressive deterioration toward acute hypoxemic respiratory failure. He was transferred to the ICU and intubated on day 19 of his stay and expired a short time after. DISCUSSION: An extensive literature has revealed few cases involving COVID-19 induced AP. While many theories behind this disease process have been discussed, there is no definitive explanation for the pathogenesis. There has been evidence showing ACE2 receptor expression on the pancreas is responsible for damage during a COVID-19 infection. One such study out of China showed 1-2% of non-severe COVID patients and 17% of severe COVID patients exhibited some degree of pancreatic damage. Endothelial damage from the patient's inflammatory response can cause activation of the cytokine cascade. Too much IL-6 activation, as seen with COVID-19, can cause a cytokine storm leading to pancreatitis. While certain viral illnesses have a well-established link to AP, more research needs to be undertaken to determine whether a true relationship exists with the coronavirus. This case highlights that during this global pandemic, unexplained acute pancreatitis may be a presenting symptom of COVID-19 infection.