Skip to main content

Acute pancreatitis associated with severe acute respiratory syndrome coronavirus-2 infection: a case report and review of the literature



We report a case of Severe acute respiratory syndrome coronavirus-2 infection with acute pancreatitis as the only presenting symptom. To the best of our knowledge, there are few case reports of the same presentation.

Case presentation

An otherwise healthy 44-year-old white male from Egypt presented to the hospital with severe epigastric pain and over ten attacks of nonprojectile vomiting (first, gastric content, then bilious). Acute pancreatitis was suspected and confirmed by serum amylase, serum lipase, and computed tomography scan that showed mild diffuse enlargement of the pancreas. The patient did not have any risk factor for acute pancreatitis, and extensive investigations did not reveal a clear etiology. Given a potential occupational exposure, a nasopharyngeal swab for polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 was done, which was positive despite the absence of the typical symptoms of severe acute respiratory syndrome coronavirus 2 such as fever and respiratory symptoms. The patient was managed conservatively. For pancreatitis, he was kept nil per os for 2 days and received intravenous lactated Ringer’s (10 ml per kg per hour), nalbuphine, alpha chymotrypsin, omeprazole, and cyclizine lactate. For severe acute respiratory syndrome coronavirus 2, he received a 5-day course of intravenous azithromycin (500 mg per day). He improved quickly and was discharged by the fifth day. We know that abdominal pain is not a rare symptom of severe acute respiratory syndrome coronavirus 2, and we also know that elevated levels of serum amylase and lipase were reported in severe acute respiratory syndrome coronavirus-2 patients, especially those with severe symptoms. However, the association between severe acute respiratory syndrome coronavirus-2 infection and idiopathic acute pancreatitis is rare and has been reported only a few times.


We believe further studies should be conducted to determine the extent of pancreatic involvement in severe acute respiratory syndrome coronavirus-2 patients and the possible causality between severe acute respiratory syndrome coronavirus 2 and acute pancreatitis. We reviewed the literature regarding the association between severe acute respiratory syndrome coronavirus 2 and acute pancreatitis patients. Published data suggest that severe acute respiratory syndrome coronavirus 2 possibly could be a risk factor for acute pancreatitis.

Peer Review reports


With over 149 million confirmed cases and 3.14 million deaths worldwide as of 29 April 2021, coronavirus disease 2019 (COVID-19) has declared itself the most significant global health emergency humanity had to face in decades [1]. After more than 10 months of the pandemic, we still lack a comprehensive understanding of the virus pathophysiology and how it manifests in different patients. Gastrointestinal (GI) manifestations were reported in about 18% of patients, with diarrhea being the most commonly reported GI symptom [2] that is most likely due to alteration of enterocyte permeability [3]. Mild-to-moderate liver injury was reported as well, and the exact mechanism is still not fully understood [3]. Acute abdominal pain has also been reported, and its exact pathophysiology is still elusive. Acute pancreatitis was reported a few times as a cause of abdominal pain in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and it is not clear if the virus could involve the pancreas specifically. We are reporting a case of COVID-19 presenting with acute pancreatitis without other risk factors for pancreatitis.

Case presentation

A previously healthy 44-year-old white male presented to the emergency department with severe epigastric pain radiating to the back and frequent vomiting (over ten attacks, first gastric content, then bilious with no blood) for 3 days on 22 June 2020. Four days before the beginning of his abdominal symptoms, the patient received a laboratory diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after undergoing a nasopharyngeal swab for reverse-transcription polymerase chain reaction (RT-PCR) to detect SARS-CoV-2 infection as part of surveillance screening after contacting several COVID-19 patients during his work in a hotel in Sharm El-Sheikh, Egypt, and the patient was asked to self-isolate. However, he presented to our care after 5 days of SARS-COV-2 diagnosis with acute pancreatitis. The patient did not have any respiratory symptoms at that time.

During history taking, the patient denied any respiratory symptoms such as cough or dyspnea. The patient denied smoking, alcohol, or drug intake (illicit or therapeutic except for occasional use of paracetamol for right knee pain). The patient was a middle-class worker who denied exposure to any hazardous substances at his work place. He also denied any previous similar attacks of abdominal pain. There was no family history of similar attacks. His vital signs were as follows: blood pressure of 94/50 mmHg, pulse rate of 112 beats per minute, respiratory rate of 27 breaths per minute, temperature of 37.5 °C, and oxygen saturation of 98% on room air. Abdominal examination revealed marked tenderness in the epigastric region without distension. Neurological examination did not reveal any abnormalities. Intravenous fluid resuscitation was started immediately with a bolus of 1.5 L of lactated Ringer’s.

A repeat nasopharyngeal Reverse transcription polymerase chain reaction (RT-PCR) was performed on the day of admission to the hospital as a part of the local protocols for suspected cases. The results came back positive on 24 June 2020. The patient was then transferred from the medical ward to an isolation center in the same hospital, explicitly dedicated to COVID-19 patients.

An abdominal X-ray was done and was unremarkable. However, abdominal–pelvic ultrasonography revealed mild diffuse enlargement of the pancreatic head with normal gall bladder and biliary tract. Serum amylase was 773, and serum lipase was 286 (Table 1). The diagnosis of mild acute pancreatitis was confirmed with an abdominal CT scan that revealed mild diffuse enlargement of the pancreas (Figure 1). The patient was managed conservatively for 4 days. For pancreatitis, he was kept NPO for 2 days during which he received 10 ml/kg/hour of lactated Ringer’s; he also received nalbuphine (10–20 mg per day, intramuscular) for analgesia, omeprazole (40 mg once daily, intravenous) for ulcer prophylaxis and cyclizine lactate (50 mg twice daily, intravenous) for vomiting. On the third day, anorexia and vomiting subsided, and the patient was started on oral feeding, which he tolerated well. On the fifth day, the patient was vitally stable and symptom-free and was advised to continue his SARS-CoV-2 treatment from home, including ascorbic acid (1 g per day, oral) and zinc sulfate (220 mg per day, oral). Abdominal ultrasound was repeated on discharge and again showed no gallstones. At 30 days follow-up, the patient was well and did not have any complaints.

Table 1 Laboratory results on admission
Fig. 1
figure 1

Computed tomography scan of the abdomen showing diffuse enlargement of the pancreas


Although rare, acute pancreatitis can be caused by viral, bacterial, fungal, and parasitic infections. Viral pancreatitis is known to be caused by mumps, cytomegalovirus, hepatitis B virus, herpes simplex virus, varicella-zoster virus, and human immunodeficiency virus (HIV) [4,5,6]. Although coronaviruses are not known to cause pancreatitis in humans, the 2003 SARS was associated with damage to the endocrine pancreas and acute diabetes [7]. This effect was explained by damage to acinar cells through the virus binding to angiotensin-converting enzyme 2 (ACE2) receptors [7].

Liu et al. reported elevated amylase and lipase in 16.41% and 1.85% of patients with severe and mild SARS-CoV-2 infections, respectively, suggesting some degree of pancreatic injury [8]. This injury’s exact pathophysiology is not well understood, but SARS-CoV-2 may involve the exocrine pancreas in the same manner SARS involves the endocrine pancreas: through ACE2 receptor binding, especially now that we know that SARS-CoV-2 binds ACE2 receptors ten times stronger than the 2003 SARS [9]. A recent study published by Müller et al. found that SARS-CoV-2 has the ability to infect and replicates in β-cell of pancreatic islets of Langerhans as they detected SARS-CoV-2 nucleocapsid protein in the pancreatic cells of postmortem patients [10]. Their findings may explain the reason behind the metabolic dysregulations of COVID-19 patients, such as impaired glucose homeostasis and abnormal amylase or lipase levels [8].

We report the first African case report of acute pancreatitis presenting as SARS-CoV-2 infection. Our patient had acute acalculous pancreatitis in association with SARS-CoV-2 infection. We managed to exclude alcoholism, drugs, hypertriglyceridemia, hypercalcemia (by laboratory testing), and trauma (by history) as potential etiologies. The patient denied any previous attacks or family history of similar symptoms. We did not test our patient for autoimmune pancreatitis since this was not feasible at our institution. Also, we did not test for viral causes of pancreatitis other than hepatitis B virus and human immunodeficiency virus, which both were negative.

We searched the literature in PubMed/Medline up to 3 January 2021 to identify published case reports of COVID-19 associated with pancreatitis. We identified only 29 cases published in 25 articles (Table 2). SARS-CoV-2 infections were diagnosed with RT-PCR in all cases except one case with antibody testing. Three cases were in the pediatric age group < 18 years. Including our case, patients have a mean age of 43.5 years, and 14 were males (46.6%). The majority of the cases had abdominal pain and/or vomiting, 82% of patients had elevated serum lipase, and almost all patients had elevated serum lipase and/or amylase. Moreover, 72% of patients had abdominal CT findings suggestive of pancreatitis. All patients were discharged alive, except two patients were still in the intensive care unit (ICU), and only one patient died (Table 3).

Table 2 Published cases of acute pancreatitis associated with SARS-CoV-2 infection
Table 3 Summary of the previous case reports important statistics

Acute pancreatitis appears to be an infrequent complication/association of COVID-19. One retrospective study from the USA analyzing 11,883 patients with COVID-19 found that the point prevalence of pancreatitis was 0.27% (32 patients) [11]. However, another prospective international study of acute pancreatitis during the COVID-19 pandemic concluded that acute pancreatitis with SARS-CoV-2 infection has a higher risk of severity and poor clinical outcomes, including the risk of organ dysfunction higher 30-day inpatient mortality compared with acute pancreatitis patients who are SARS-CoV-2-negative [12].


Until solid evidence on the relation between pancreatitis and SARS-CoV-2 is provided, we believe acute pancreatitis should be considered a potential explanation for acute abdominal pain in SARS-CoV-2 patients. Such evidence should rise from well-designed epidemiological studies as well as autopsy studies.

Availability of data and materials

All data and reports are present upon request.



Severe acute respiratory syndrome coronavirus 2


Reverse-transcription polymerase chain reaction


Nil per os


  1. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020;20(5):533–4.

    Article  CAS  Google Scholar 

  2. Cheung KS, Hung IFN, Chan PPY, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung TWH, Tam AR, et al. Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from a Hong Kong Cohort: systematic review and meta-analysis. Gastroenterology. 2020;159(1):81–95.

    Article  CAS  Google Scholar 

  3. Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020;158(6):1518–9.

    Article  CAS  Google Scholar 

  4. Kottanattu L, Lava SAG, Helbling R, Simonetti GD, Bianchetti MG, Milani GP. Pancreatitis and cholecystitis in primary acute symptomatic Epstein-Barr virus infection: systematic review of the literature. J Clin Virol. 2016;82:51–5.

    Article  Google Scholar 

  5. Cruickshank AH, Benbow EW. Bacterial, granulomatous, viral and parasitic lesions of the pancreas. In: Cruickshank AH, Benbow EW, editors. Pathology of the pancreas. Springer: London; 1995. p. 319–34.

    Chapter  Google Scholar 

  6. Naficy K, Nategh R, Ghadimi H. Mumps pancreatitis without parotitis. BMJ. 1973;1(5852):529.

    Article  CAS  Google Scholar 

  7. Yang J-K, Lin S-S, Ji X-J, Guo L-M. Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes. Acta Diabetol. 2010;47(3):193–9.

    Article  CAS  Google Scholar 

  8. Liu F, Long X, Zhang B, Zhang W, Chen X, Zhang Z. ACE2 expression in pancreas may cause pancreatic damage after SARS-CoV-2 infection. Clin Gastroenterol Hepatol. 2020;18(9):2128-2130.e2122.

    Article  CAS  Google Scholar 

  9. Wrapp D, Wang N, Corbett KS, Goldsmith JA, Hsieh CL, Abiona O, Graham BS, McLellan JS. Cryo-EM structure of the 2019-nCoV spike in the prefusion conformation. Science (New York, NY). 2020;367(6483):1260–3.

    Article  CAS  Google Scholar 

  10. Müller JA, Groß R, Conzelmann C, Krüger J, Merle U, Steinhart J, Weil T, Koepke L, Bozzo CP, Read C, et al. SARS-CoV-2 infects and replicates in cells of the human endocrine and exocrine pancreas. Nat Metab. 2021;3:149–65.

    Article  Google Scholar 

  11. Inamdar S, Benias PC, Liu Y, Sejpal DV, Satapathy SK, Trindade AJ. Northwell C-RC: prevalence, risk factors, and outcomes of hospitalized patients with coronavirus disease 2019 presenting as acute pancreatitis. Gastroenterology. 2020;159(6):2226-2228.e2222.

    Article  CAS  Google Scholar 

  12. Pandanaboyana S, Moir J, Leeds JS, Oppong K, Kanwar A, Marzouk A, Belgaumkar A, Gupta A, Siriwardena AK, Haque AR, et al. SARS-CoV-2 infection in acute pancreatitis increases disease severity and 30-day mortality: COVID PAN collaborative study. Gut. 2021;70:1061–9.

    Article  CAS  Google Scholar 

  13. Meyers MH, Main MJ, Orr JK, Obstein KL. A case of COVID-19-induced acute pancreatitis. Pancreas. 2020;49(10):e108.

    Article  CAS  Google Scholar 

  14. Samies NL, Yarbrough A, Boppana S. Pancreatitis in pediatric patients with COVID-19. J Pediatric Infect Dis Soc. 2020;10:57–9.

    Article  Google Scholar 

  15. Fernandes DA, Yumioka AS, Filho HRM. SARS-CoV-2 and acute pancreatitis: a new etiological agent? Rev Esp Enferm Dig. 2020;112(11):890.

    PubMed  Google Scholar 

  16. Lakshmanan S, Malik A. Acute pancreatitis in mild COVID-19 infection. Cureus. 2020;12(8):e9886.

    PubMed  PubMed Central  Google Scholar 

  17. Kurihara Y, Maruhashi T, Wada T, Osada M, Oi M, Yamaoka K, Asari Y. Pancreatitis in a patient with severe coronavirus disease pneumonia treated with veno-venous extracorporeal membrane oxygenation. Intern Med. 2020;59(22):2903–6.

    Article  CAS  Google Scholar 

  18. Alves AM, Yvamoto EY, Marzinotto MAN, Teixeira ACS, Carrilho FJ. SARS-CoV-2 leading to acute pancreatitis: an unusual presentation. Braz J Infect Dis. 2020;24(6):561–4.

    Article  Google Scholar 

  19. Wang K, Luo J, Tan F, Liu J, Ni Z, Liu D, Tian P, Li W. Acute pancreatitis as the initial manifestation in 2 cases of COVID-19 in Wuhan, China. Open Forum Infect Dis. 2020;7(9):ofaa324.

    Article  Google Scholar 

  20. Patnaik RNK, Gogia A, Kakar A. Acute pancreatic injury induced by COVID-19. IDCases. 2020;22:e00959.

    Article  Google Scholar 

  21. Kumaran NK, Karmakar BK, Taylor OM. Coronavirus disease-19 (COVID-19) associated with acute necrotising pancreatitis (ANP). BMJ Case Rep. 2020;13(9):e237903.

    Article  Google Scholar 

  22. Gonzalo-Voltas A, Uxia Fernández-Pérez-Torres C, Baena-Díez JM. Acute pancreatitis in a patient with COVID-19 infection. Med Clin (Engl Ed). 2020;155(4):183–4.

    CAS  Google Scholar 

  23. Cheung S, Delgado Fuentes A, Fetterman AD. Recurrent acute pancreatitis in a patient with COVID-19 infection. Am J Case Rep. 2020;21:e927076.

    PubMed  PubMed Central  Google Scholar 

  24. Kataria S, Sharif A, Ur Rehman A, Ahmed Z, Hanan A. COVID-19 induced acute pancreatitis: a case report and literature review. Cureus. 2020;12(7):e9169.

    PubMed  PubMed Central  Google Scholar 

  25. Brikman S, Denysova V, Menzal H, Dori G. Acute pancreatitis in a 61-year-old man with COVID-19. CMAJ Can Med Assoc J. 2020;192(30):E858-e859.

    Article  CAS  Google Scholar 

  26. Mazrouei SSA, Saeed GA, Al Helali AA. COVID-19-associated acute pancreatitis: a rare cause of acute abdomen. Radiol Case Rep. 2020;15(9):1601–3.

    Article  Google Scholar 

  27. Bokhari S, Mahmood F. Case report: novel coronavirus-a potential cause of acute pancreatitis? Am J Trop Med Hyg. 2020;103(3):1154–5.

    Article  Google Scholar 

  28. Alloway BC, Yaeger SK, Mazzaccaro RJ, Villalobos T, Hardy SG. Suspected case of COVID-19-associated pancreatitis in a child. Radiol Case Rep. 2020;15(8):1309–12.

    Article  Google Scholar 

  29. Rabice SR, Altshuler PC, Bovet C, Sullivan C, Gagnon AJ. COVID-19 infection presenting as pancreatitis in a pregnant woman: a case report. Case Rep Womens Health. 2020;27:e00228.

    Article  Google Scholar 

  30. Pinte L, Baicus C. Pancreatic involvement in SARS-CoV-2: case report and living review. J Gastrointestin Liver Dis. 2020;29(2):275–6.

    Article  Google Scholar 

  31. Meireles PA, Bessa F, Gaspar P, Parreira I, Silva VD, Mota C, Alvoeiro L. Acalculous acute pancreatitis in a COVID-19 patient. Eur J Case Rep Intern Med. 2020;7(6):1710.

    Google Scholar 

  32. Miao Y, Lidove O, Mauhin W. First case of acute pancreatitis related to SARS-CoV-2 infection. Br J Surg. 2020;107(8):e270.

    Article  CAS  Google Scholar 

  33. Aloysius MM, Thatti A, Gupta A, Sharma N, Bansal P, Goyal H. COVID-19 presenting as acute pancreatitis. Pancreatology. 2020;20(5):1026–7.

    Article  CAS  Google Scholar 

  34. Hadi A, Werge M, Kristiansen KT, Pedersen UG, Karstensen JG, Novovic S, Gluud LL. Coronavirus disease-19 (COVID-19) associated with severe acute pancreatitis: case report on three family members. Pancreatology. 2020;20(4):665–7.

    Article  CAS  Google Scholar 

  35. Anand ER, Major C, Pickering O, Nelson M. Acute pancreatitis in a COVID-19 patient. Br J Surg. 2020;107(7):e182.

    Article  CAS  Google Scholar 

  36. Hassani AH, Beheshti A, Almasi F, Ketabi Moghaddam P, Azizi M, Shahrokh S. Unusual gastrointestinal manifestations of COVID-19: two case reports. Gastroenterol Hepatol Bed Bench. 2020;13(4):410–4.

    PubMed  PubMed Central  Google Scholar 

  37. Kandasamy S. An unusual presentation of COVID-19: acute pancreatitis. Ann Hepatobiliary Pancreat Surg. 2020;24(4):539–41.

    Article  Google Scholar 

Download references




This study did not receive any grant or funding from any department or institute.

Author information

Authors and Affiliations



Conceptualization: ASE, ARF. Data curation: ASE, ARF, SMM. Investigation: ASE, ARF, SMM, ME. Writing, original draft: ASE, ARF, SMM, ME. Writing, review and editing: ASE, ARF, SMM, ME. All authors have read and approved the manuscript

Corresponding author

Correspondence to Muhammed Elhadi.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interest

The authors declare that they have no competing interests and no relationship with the industry.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Eldaly, A.S., Fath, A.R., Mashaly, S.M. et al. Acute pancreatitis associated with severe acute respiratory syndrome coronavirus-2 infection: a case report and review of the literature. J Med Case Reports 15, 461 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: