Authors Contribution:
Abstract : The entire world has been grabbed by the Severe Acute Respiratory Syndrome (SARS-CoV-2) virus infection since mid-December, 2019. SARS-CoV-2 as a new virus, there is scarcity of established data regarding it nature, clinical manifestation and treatment protocol and outcome. Initially, Coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 virus is strikingly thought to be manifested by respiratory illness such as cough, chest tightness, and dyspnea. Sequentially, polymorphic atypical presentations including cardiac, hepatic, renal, musculoskeletal, gastrointestinal and neurological features have been manifested by COVID-19 with time flying. Therefore, we are presenting a confirmed case of COVID-19 who developed acute pancreatitis during disease process without any known aggravating factors of it.
Keywords: SARS-CoV-2, COVID-19, Atypical Presentations, Acute Pancreatitis,
Background: A series of pneumonia had been identified by a homological virus similar to severe respiratory syndrome coronavirus (SARS-CoV) which was classified as a novel coronavirus-19, later on SARS-CoV-2 virus and the disease as COVID-19 in Wuhan city, Hubei province, China in December 2019.1,2 Very soon, the new contagious virus spread all over the world including 213 countries and territories with an estimation of more than 15 million total confirmed SARS-CoV-2 case and six hundred thousand people died of COVID-19 according to the live update of Worldometer by July 22, 2020.3 Initially COVID-19 manifested by respiratory symptoms including fever, dry cough, dyspnea, pharyngodynia, nasal congestion, rhinorrhea.4 Gradually a lot of atypical presentations including various gastrointestinal symptoms, ageusia, anosmia, infarcted or hemorrhagic stroke, Guillain-Barré syndrome, acute necrotizing encephalopathy, cardiac arrhythmias , pericarditis, myocarditis, heart failure, pulmonary embolism, deep venous or arterial thrombosis, acute kidney injury even without prior respiratory symptoms.5 However It is strongly believed that the severity with multi-organ failure of COVID-19 results as a part of cytokine release syndrome or cytokine storm. Hereby, we are reporting an atypical case who developed acute pancreatitis during the disease process of COVID-19 without any precipitating causes.
Case Presentation: A 57 year old female physician with previous history of hypertension, type 2 diabetes mellitus and active malignancy of breast and larynx developed high grade fever, generalized body ache, loss of smell, fatigue and arthralgia for past two days. On the basis of the high indexed symptoms of COVID-19, Real time Polymerase Chain Reaction (RT-PCR) was ordered which had become positive. We had found high CRP, serum ferritin and mild to moderate involvement of both lungs having diffuse ground glass opacities with crazy-paving pattern small consolidation in the chest CT scan. (Table-1, Figure-1) Acquisition of confirmed COVID-19 report, she was prescribed standard dose of Favipiravir and prophylactic dose of Enoxaparin 40IU (International Unit) daily. She remained clinically stable with remission of fever and improvement of her symptoms including her oxygen saturation 95-97% on room air for next two days. On the 5th day of her COVID-19 disease, her oxygen saturation had been going down 87% on the room air which made to get herself admitted in a local private hospital in Jashore, Bangladesh. Shortly after oxygen inhalation at a rate of 4 liters/minute by nasal cannula, her oxygen saturation was maintained by 98%. On the next day, her oxygen saturation was maintained at 96-97% on the room air and she felt eventually well on the day time. But she developed mild epigastric pain without any other lateralizing sign and symptoms which was relieved by supportive treatment. Therefore on the 9th day of her COVID-19 positive, she again developed severe epigastric pain radiating to the back with vomiting for two times. Clinical examination revealed upper abdominal tenderness with presence of bowel sound. Both clinical signs and symptoms suggested high index probability of acute pancreatitis. Therefore we had suggested investigation including complete blood count, C- reactive protein, liver function test, serum creatinine, serum electrolytes, serum lipase, D-dimer and CT scan of abdomen. Therefore she was diagnosed as a case of acute pancreatitis on the basis of high serum Lipase (8352 U/L) and abdominal CT scan (moderately swollen pancreas) according to the Atlanta classification and definition by international consensus.(Table-2, Figure-3)
Investigation: We had chalked out the base line investigations after her diagnosis as COVID-19 including CBC, RBS, S. Creatinine, SGPT, CRP, D-Dimer, S, Ferritin, HbA1c, S. electrolytes, prothrombin time with INR (international normalization ratio) and chest radiography. (Table-1) Prognostic features of acute pancreatitis had extensively evaluated including S. Albumin, S. Calcium. Fasting lipid profile was measure to see the triglyceride level for exclusion of precipitating factor.(Table-2)
Table- 1 Report of base line investigations following COVID-19 positive