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CASE REPORT  
Year : 2022  |  Volume : 65  |  Issue : 4  |  Page : 928-930
Acute pancreatitis masquerading as mesentric growth in COVID-19 patient: A case report


Department of Pathology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India

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Date of Submission24-Jun-2021
Date of Acceptance05-Jan-2022
Date of Web Publication08-Jun-2022
 

   Abstract 


COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It commonly affects the respiratory system, producing pneumonia-like symptoms. Among extrapulmonary manifestations, involvement of the gastrointestinal tract is common with symptoms of nausea, vomiting, diarrhea, and abdominal pain. Coronavirus acts by targeting the ACE-2 receptors in the alveoli of the lungs, but because these receptors are also present in other organs, such as the pancreas, it can affect the pancreas as well, thus causing acute pancreatitis. We here discuss a case of a 72-year-old hypertensive male with COVID-19 who presented with atypical presentation of acute abdominal pain and a few episodes of vomiting. Laboratory investigations were inconclusive. Imaging findings were suggestive of small bowel obstruction and perforation; thus, an exploratory laparotomy was done in which a mesenteric growth was found, reported as acute pancreatitis on histopathology. Therefore, attention should be paid to the pancreatic involvement and atypical presentations in COVID-19 patients.

Keywords: Acute pancreatitis, COVID-19, mesenteric growth

How to cite this article:
Agrawal S, Harsh A. Acute pancreatitis masquerading as mesentric growth in COVID-19 patient: A case report. Indian J Pathol Microbiol 2022;65:928-30

How to cite this URL:
Agrawal S, Harsh A. Acute pancreatitis masquerading as mesentric growth in COVID-19 patient: A case report. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 Nov 30];65:928-30. Available from: https://www.ijpmonline.org/text.asp?2022/65/4/928/359364





   Introduction Top


The SARS-CoV-2 (COVID-19) infection is an ongoing global health crisis affecting lives all over the world. It primarily affects the respiratory system, producing pneumonia-like symptoms. However, it is well known now that extrapulmonary manifestations such as thrombotic complications, gastrointestinal symptoms, acute coronary syndromes, acute kidney injury, and hepatocellular injury are not that uncommon.[1] The gastrointestinal symptoms alone have been reported to occur in 17.6% of infected patients.[2]

We report a case of a COVID-19 patient who presented with acute severe abdominal pain. A mesenteric growth was found on laparotomy which was diagnosed as acute pancreatitis on histopathology.


   Case Report Top


A 72-year-old male was admitted with complaints of acute severe abdominal pain, nausea, and vomiting (3–4 times). The patient was hypertensive with no past history of diabetes, obesity, alcohol intake, or gall stones. HRCT of the thorax done 3 days prior to admission revealed bilateral subpleural, patchy ground-glass densities with a CT severity score of 14 out of 25. RT-PCR of the nasopharyngeal swab was positive for COVID-19 infection. Laboratory investigations were done when the patient was admitted (day 1) and were repeated during the course of admission [Table 1]. Serum amylase and lipase were within the normal range on the day of admission. Laboratory investigations before admission were not available.
Table 1: Blood investigations on various days.

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CECT of the abdomen was done, findings of which were suggestive of intestinal obstruction and perforation in the region of proximal ileum. The exploratory laparotomy was taken into consideration in which the surgeon did not find any perforation; instead, they found a mesenteric growth which was excised for histopathological examination. The CT images of the abdomen could not be collected from the patient.

Gross examination- Formalin-fixed specimen comprised a segment of the intestine measuring 11 cm in length with uniform luminal diameter throughout the entire length. A gray-white area of 5 cm × 4 cm × 4 cm was attached to the intestine on mesenteric border involving the serosal aspect of the intestine. Cut surface was gray-white with few congested vessels [Figure 1]a.
Figure 1: (a) Gross specimen – gray- white, lobulated, soft to firm tissue adherent to the intestine. (b) H and E, 10× – Acinar cell homogenization. (c) H and E, 10× – Inflammation extending to the adjacent intestinal wall.

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Microscopic examination of the gray-white area revealed pancreatic tissue showing epithelial cell degeneration, interstitial edema, congestion, hemorrhage, and leucocytic infiltration along with a small focus of acinar cell homogenization [Figure 1]b. Foci of mesenteric fat necrosis infiltrated by neutrophils, lymphocytes, and histiocytes were present. The inflammation extended to serosa and adjacent intestinal wall [Figure 1]c. The case was reported as acute pancreatitis.


   Discussion Top


Acute pancreatitis is an inflammatory condition of the exocrine pancreas. Despite gallstones and alcohol abuse being reported as the more common causes, infectious agents, especially viruses such as hepatitis virus, herpes simplex, cytomegalovirus, mumps, and influenza, are responsible for approximately 10% of cases.[3] Therefore, SARS-CoV-2 must be considered as a potential cause of pancreatitis.

The spike subunit of SARS-CoV-2 engages angiotensin-converting enzyme 2 (ACE2) as an entry receptor, which facilitates the entry of the virus into target cells. ACE2 is expressed in alveolar cells of the lungs but is also abundant in the gastrointestinal tract and pancreas. The expression of ACE2 in the pancreas is found to be higher than in the lungs and is expressed in both the exocrine glands and islets of the pancreas, thus becoming potential targets of SARS-CoV-2, which can result in direct pancreatic injury. In addition, indirect mechanisms such as exacerbated systemic inflammatory response syndrome (SIRS), endothelial damage, thrombo-inflammation, and maladaptation of ACE2-related pathways might all contribute to the extrapulmonary manifestations of COVID-19.[4],[5],[6]

The revised Atlanta classification of acute pancreatitis requires two out of the three criteria: a) typical abdominal pain (pancreatic pain), b) elevated serum amylase or lipase more than three times above the upper normal limit, and c) suggestive imaging findings.[7]

The patient in our case presented with sudden onset of acute abdominal pain associated with nausea and vomiting. The probable pathogenesis in this case could be an intestinal obstruction as a sequela of acute pancreatitis. All the radiology and laboratory parameters were in favor of intestinal obstruction with impending perforation, while the histopathology confirmed a case of acute pancreatitis. Normal levels of pancreatic enzymes can be explained by the small foci of acinar cell degeneration and homogenization on microscopy.


   Differential Diagnosis Top


Acute abdomen may be caused by infection, inflammation, vascular occlusion, or obstruction. Biliary colic/cholecystitis, ureteric obstruction, bowel obstruction, pancreatitis, and ruptured visceral artery aneurysm can present as acute abdomen.

Heterotropic pancreas, a relatively uncommon congenital anomaly, can present as acute pancreatitis. Heterotropic pancreas has anatomically different pancreatic tissue from the main gland without vascular or ductal continuity. Most cases are found in the upper gastrointestinal tract. Mesenteric manifestations are reported in some studies. The majority of heterotropic pancreatitis lesions are solitary and measure smaller than 3.0 cm. Usually, the patient remains asymptomatic, and heterotropic pancreas is incidentally detected during surgery, endoscopy, or autopsy. The complications of heterotropic pancreas might occur due to inflammation, pseudocyst formation, endocrine dysfunction, or malignant transformation. The radiological, laboratory, and histopathology findings did not support heterotropic pancreas in our case.[8],[9]

Small bowel obstruction following an episode of acute pancreatitis is rarely documented in the literature and tends to be the result of retroperitoneal inflammation. The small bowel is susceptible to inflammation due to its proximity to the anterior surface of the pancreas. The extravasated products released in response to inflammation are rich in enzymes and can travel to the colon and small bowel, making it vulnerable to inflammatory complications, that is, mechanical obstruction. In this case, the radiological findings of intestinal obstruction and perforation and normal pancreatic enzyme assay mislead the surgeons and acute pancreatitis remained unrevealed.[10]


   Conclusion Top


The knowledge and understanding about tropism between SARS-CoV-2 and the pancreas are evolving. In COVID, pancreatic injury can be explained by the expression of ACE-2 receptors in the pancreas and as a part of systemic inflammatory response. It is imperative to keep in mind the possible presentation of acute pancreatitis in COVID-19 patients. The awareness of uncommon presentations is crucial to avoid misdiagnosis and delay in proper management.

Informed consent

This study was a case report study, patient identity remained anonymous, and the informed consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, et al. Extrapulmonary manifestations of COVID-19. Nat Med 2020;26:1017-32.  Back to cited text no. 1
    
2.
Cheung KS, Hung IFN, Chan PPY, Lung KC, Tso E, Liu R, 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;159:81-95.  Back to cited text no. 2
    
3.
Rawla P, Bandaru SS, Vellipuram AR. Review of infectious etiology of acute pancreatitis. Gastroenterology Res 2017;10:153-8.  Back to cited text no. 3
    
4.
Hoffmann M, Kleine-Weber H, Schroeder S, Krüger N, Herrler T, Erichsen S, et al. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell 2020;181:271-80.  Back to cited text no. 4
    
5.
Wifi MN, Nabil A, Awad A, Eltatawy R. COVID-induced pancreatitis: Case report. Egypt J Intern Med 2021;33:10.  Back to cited text no. 5
    
6.
AlHarmi R, Fateel T, Sayed Adnan J, AlAwadhi K. Acute pancreatitis in a patient with COVID-19. BMJ Case Rep 2021;14:e239656.  Back to cited text no. 6
    
7.
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis--2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-11.  Back to cited text no. 7
    
8.
Tang XB, Liao MY, Wang WL, Bai YZ. Mesenteric heterotopic pancreas in a pediatric patient: A case report and review of literature. World J Clin Cases 2018;6:847-53.  Back to cited text no. 8
    
9.
de Kok BM, de Korte FI, Perk LE, Terpstra V, Mieog JSD, Zijta FM. Acute clinical manifestation of mesenteric heterotopic pancreatitis: A pre- and postoperative confirmed case. Case Rep Gastrointest Med 2018;2018:5640379. doi: 10.1155/2018/5640379.  Back to cited text no. 9
    
10.
Sunkara T, Etienne D, Caughey ME, Gaduputi V. Small bowel obstruction secondary to acute pancreatitis. Gastroenterology Res 2017;10:42-4.  Back to cited text no. 10
    

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Correspondence Address:
Sakshi Agrawal
C-80, Ram Das Marg, Tilak Nagar, Jaipur - 302 004, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpm.ijpm_651_21

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