Acute pancreatitis associated with severe acute respiratory syndrome coronavirus-2 infection: a case report and review of the literature
Journal of Medical Case Reports volume 15, Article number: 461 (2021)
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.
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.
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 . 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  that is most likely due to alteration of enterocyte permeability . Mild-to-moderate liver injury was reported as well, and the exact mechanism is still not fully understood . 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.
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.
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 . This effect was explained by damage to acinar cells through the virus binding to angiotensin-converting enzyme 2 (ACE2) receptors .
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 . 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 . 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 . 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 .
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).
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) . 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 .
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
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.
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.
Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020;158(6):1518–9.
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.
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.
Naficy K, Nategh R, Ghadimi H. Mumps pancreatitis without parotitis. BMJ. 1973;1(5852):529.
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.
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.
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.
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.
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.
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.
Meyers MH, Main MJ, Orr JK, Obstein KL. A case of COVID-19-induced acute pancreatitis. Pancreas. 2020;49(10):e108.
Samies NL, Yarbrough A, Boppana S. Pancreatitis in pediatric patients with COVID-19. J Pediatric Infect Dis Soc. 2020;10:57–9.
Fernandes DA, Yumioka AS, Filho HRM. SARS-CoV-2 and acute pancreatitis: a new etiological agent? Rev Esp Enferm Dig. 2020;112(11):890.
Lakshmanan S, Malik A. Acute pancreatitis in mild COVID-19 infection. Cureus. 2020;12(8):e9886.
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.
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.
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.
Patnaik RNK, Gogia A, Kakar A. Acute pancreatic injury induced by COVID-19. IDCases. 2020;22:e00959.
Kumaran NK, Karmakar BK, Taylor OM. Coronavirus disease-19 (COVID-19) associated with acute necrotising pancreatitis (ANP). BMJ Case Rep. 2020;13(9):e237903.
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.
Cheung S, Delgado Fuentes A, Fetterman AD. Recurrent acute pancreatitis in a patient with COVID-19 infection. Am J Case Rep. 2020;21:e927076.
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.
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.
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.
Bokhari S, Mahmood F. Case report: novel coronavirus-a potential cause of acute pancreatitis? Am J Trop Med Hyg. 2020;103(3):1154–5.
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.
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.
Pinte L, Baicus C. Pancreatic involvement in SARS-CoV-2: case report and living review. J Gastrointestin Liver Dis. 2020;29(2):275–6.
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.
Miao Y, Lidove O, Mauhin W. First case of acute pancreatitis related to SARS-CoV-2 infection. Br J Surg. 2020;107(8):e270.
Aloysius MM, Thatti A, Gupta A, Sharma N, Bansal P, Goyal H. COVID-19 presenting as acute pancreatitis. Pancreatology. 2020;20(5):1026–7.
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.
Anand ER, Major C, Pickering O, Nelson M. Acute pancreatitis in a COVID-19 patient. Br J Surg. 2020;107(7):e182.
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.
Kandasamy S. An unusual presentation of COVID-19: acute pancreatitis. Ann Hepatobiliary Pancreat Surg. 2020;24(4):539–41.
This study did not receive any grant or funding from any department or institute.
Ethics approval and consent to participate
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.
The authors declare that they have no competing interests and no relationship with the industry.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
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). https://doi.org/10.1186/s13256-021-03026-7