Treatment: With this above scenario of acute pancreatitis she had been treated with adequate bowel rest, intravenous fluid therapy, injectable broad spectrum antibiotics, omeprazole and pethedine. Our expert opinion suggested to stop Favipiravir due to inadequate data of a new molecule as a temporal cause of her acute pancreatitis. Gradually we noticed her uneventful improvement with this medications including stable oxygen saturation 97% on room air. Finally she was discharged on oral medications with symptoms free acute pancreatitis after test negative RT-PCR for COVID-19. We advised her to continue injection Enoxaparin as a therapeutic dose for the next 14 days at home followed by oral Rivaroxaban 10mg daily. Her ongoing antihyprertensive and antidiabetic medications Losartan Potassium and insulin were preserved respectively whereas Metformin was omitted shortly after her positive RT-PCR test of COVID-19.
Outcome and Follow-up: However her discharge period was also uneventful and we had followed her up 7 and 14days later with Complete blood count, C - reactive protein, random blood sugar, liver function test, S. creatinine, S. Lipase, S. electrolytes, D- Dimer, chest radiography, ultrasonography of whole abdomen (Table-3, Table-4, figure-3, Figure-4). She had not developed any secondary complications of acute pancreatitis during her discharge period.
Discussion: According to the Atlanta classification and definition by international consensus, acute pancreatitis can be diagnosed following presence of at least two out of three points: 1) abdominal pain suggestive of acute pancreatitis, 2) lipase or amylase more than three times higher the normal upper limit, and c) sonography or radiography findings pertinent with acute pancreatitis.7 Therefore our case has been diagnosed as an acute pancreatitis following all the criteria of Atlanta classification and definition. Though the exact mechanism of acute pancreatitis by SARS-CoV-2 infection is unknown but the cytopathic effect, systemic inflammatory responses or harmful immune response mediated by local SARS-CoV-2 replication or infection are thought to be responsible for the pathogenesis of acute pancreatitis here. However SARS-CoV-2 mediated acute pancreatitic injury had been evident8 whereas COVID-19 induced seldom established acute pancreatitis case reported till date globally.9,10
Conclusion: Wide spectrum atypical presentations including acute pancreatitis are evident by SARS-CoV-2 infection. Therefore, any manifestation of its complication should be kept as high index clinical suspicious during management of COVID-19.