Authors Contribution:
- GKA designed concept, interpreted data, reviewed literature, drafted
and gave critical review of this manuscript.
- KT and MA was involved in drafting and literature review of this
manuscript.
- MR2, TR, ABMSA, and MR 6 were
engaged in collecting data and literature review.
- SRD had given critical review for the manuscript.
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