Acute pancreatitis in a 61-year-old man with COVID-19

• Acute pancreatitis has been associated with severe coronavirus disease 2019 (COVID-19).

• Medications used to manage severe COVID-19 have been associated with acute pancreatitis.

• Unresolved abdominal pain occurring late in the course of COVID-19 warrants a thorough work-up, which may include testing for levels of amylase, lipase, liver enzymes and triglycerides, and abdominal computed tomography.

A 61-year-old previously healthy man who was not taking any medications was admitted to hospital with fever, dyspnea and cough, which he had for 5 days. Our patient had been in close contact with his father, who had confirmed coronavirus disease 2019 (COVID-19). Radiography of his chest showed bilateral opacities compatible with viral pneumonia, and results from testing of nasal and throat swabs using real-time transcription polymerase chain reaction assay were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Within 3 days of our patient’s admission to hospital, severe COVID-19 pneumonia developed,1 with tachypnea and hypoxemia that required high-flow oxygen supplementation, fever and weight loss. We initially prescribed azithromycin (500 mg daily for 3 d), hydroxychloroquine (loading dose of 800 mg on day 1, followed by 200 mg twice daily for 10 d) and zinc (50 mg twice daily for 5 d). In addition, he received acetaminophen as needed (1000 mg on 4 different occasions). We later prescribed tocilizumab (anti-interleukin-6 receptor antibody, 2 doses of 400 mg administered intravenously), dexamethasone (10 mg twice daily administered intravenously for 5 d with tapering thereafter), enoxaparin (80 mg twice daily for 10 d), lopinavir/ritonavir (2 tablets of 200 mg/50 mg twice daily for 5 d) and pantoprazole (40 mg daily administered intravenously). A culture of his sputum identified Staphylococcus aureus, and we added ciprofloxacin (400 mg twice daily administered intravenously) and clindamycin (300 mg administered orally 4 times a day for 7 d). Seven days later, our patient’s respiratory status had improved, and he no longer required high-flow oxygen.

On day 14, our patient reported sudden diffuse abdominal pain with anorexia. He was afebrile and had no vomiting or diarrhea. His abdomen was soft, with mild diffuse tenderness but no signs of peritoneal irritation. A complete blood cell count showed his level of leukocytes was elevated at 37 (normal 4.5–11.5) × 10⁹/L with 93% neutrophils, and he had an absolute lymphocyte count of 0.98 (normal 1.5–5.0) × 10⁹/L. His serum lipase level was elevated at 203 (normal 21–67) U/L, and he had a serum amylase level of 142 U/L (28–100 U/L). His levels of alkaline phosphatase and direct bilirubin were in the normal range. Contrast-enhanced computed tomography (CT) of our patient’s abdomen showed signs of pancreatitis (Figure 1).2 We diagnosed acute pancreatitis and started supportive treatment, including nothing by mouth, intravenous fluids and analgesia.

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Figure 1:

Abdominal contrast-enhanced computed tomography in a 61-year-old man recovering from severe coronavirus disease 2019 pneumonia that shows signs of acute pancreatitis, including focal parenchymal enhancement of the pancreas head with inflammatory changes in peripancreatic fat (red arrow).

Two days later, our patient’s gastrointestinal symptoms had resolved completely, and all abnormal laboratory values had returned to normal. We ran additional blood tests to investigate the cause of acute pancreatitis.3 His levels of liver enzymes and calcium were normal. His serum level of triglycerides was mildly elevated (3.18 [normal 1.8] mmol/L; his level was normal [< 1.69 mmol/L] 1 d before the onset of abdominal pain and was 3.46 mmol/L on the day after the contrast-enhanced CT). Imaging did not show gallstones, or abnormalities of the gallbladder or bile duct. Our patient did not have a medical history of pancreatitis, and he had no history of heavy consumption of alcohol.