Introduction
Coronavirus disease-2019 (COVID-19), an emerging disease of variable severity caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is primarily a respiratory illness, but manifestations vary widely, affecting multiple organ systems. There are studies coming up with post-COVID sequelae over various parameters such as diabetes, lipids, and thyroid. Here, we report four cases of acute pancreatitis (AP) in association with hypertriglyceridemia (HTG) after recovery from recent COVID-19 infection.
Case Reports
Case 1
A 38-year-old male with a body mass index of 28 with COVID pneumonia a week back, treated with antibiotics, steroids, and antivirals, presented with a 2-day history of vomiting and acute pain abdomen radiating to the back. Investigations showed raised amylase and lipase (1544 u/l). Contrast-enhanced computed tomography (CECT) abdomen showed changes of AP with peripancreatic fluid collection (modified CTSI 6). The patient did not give a history of alcohol intake, and transabdominal ultrasound did not show cholelithiasis or choledocholithiasis. His serum triglycerides were elevated at 1760 mg/dl, serum calcium was 6.7 mg/dl, and HBA1C was 9.1%. A diagnosis of new-onset diabetes mellitus and HTG AP was made. He was managed with intravenous (IV) fluids, antibiotics, insulin infusion, and other supportive measures. He had a complete resolution of symptoms, and triglycerides decreased to 380 mg/dl on the day of discharge.
Case 2
A 39-year-old male diabetic presented with acute pain abdomen in the epigastric region and recurrent vomiting for 2 days. Initial investigations showed raised amylase and lipase (899 u/l). CECT abdomen showed a bulky pancreas with peripancreatic fluid collection (modified CTSI 6). He had no history of alcohol consumption. He gave a history of mild COVID-19 infection 1 month back. Sonography had no evidence of gallstones. Serum triglycerides were elevated at 1127 mg/dl, serum calcium was 9.1 mg/dl, and HBA1C was 9.7%. A diagnosis of HTG AP was made and was managed with IV fluids and supportive measures. He improved symptomatically, and triglycerides reduced to 431 mg/dl on the 15th day.
Case 3
A 39-year-old male diabetic not on medication, with COVID-19 infection 1 month back, presented with acute pain abdomen for 1 day. His initial investigations showed raised lipase (1243 U/L), elevated triglycerides at 4442 mg/dl, and HBA1C 8.1%. Ultrasonography showed a bulky pancreas without any evidence of cholelithiasis or choledocholithiasis. A diagnosis of HTG AP was made and was managed with IV fluids, insulin infusion, and supportive measures. On discharge, he had triglycerides of 422 mg/dl. He was discharged on fenofibrate, and triglyceride levels at 1-month follow-up remained low at 220 mg/dl.
Case 4
A 50-year-old male with a history of Type 2 diabetes, which was poorly controlled, and COVID pneumonia 1 month back presented with pain abdomen. Investigations confirmed AP with elevated amylase and lipase and Ultrasound showing a bulky pancreas. Serum triglycerides were elevated at 2200 mg/dl and blood sugars were also elevated. He was managed with IV fluid, IV insulin, and supportive treatment. He improved symptomatically and triglyceride levels are 362 mg/dl at the time of discharge. He was commenced on fenofibrate.
Discussion
HTG is an uncommon, but well-established cause of AP in up to 7% of the cases.
AP, secondary to COVID-19, has been reported in many case series, either secondary to drugs or due to infection itself. SARS-CoV-2 viral infection and the resulting proinflammatory state may have a profound impact on lipid metabolism. Many viral infections such as HIV and dengue fever also demonstrate similar lipid alterations.[1,2] The alterations in lipids correlate with the severity of the underlying infection. The usual picture being lower levels of total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), and higher levels of triglycerides.[3,4] Increased plasma triglyceride levels during infection and inflammation are also a well-known phenomenon.[5] This level of triglyceride elevation is known to cause AP. There are two case reports presenting the trio of acute COVID-19, HTG and AP.[6,7] There is also evidence that drugs such as propofol and tocilizumab can cause HTG in acute setting. However, there are only few studies to date which look at chronic effects of COVID-19 on lipids. Roccaforte et al. reported that total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglyceride were found to be significantly higher after recovery than during the acute phase of COVID infection (P < 0.0001).[8] Wu et al., in 2017, assayed lipid metabolism in patients recovered from SARS and reported that triglyceride and very low-density lipoprotein cholesterol values were significantly higher than in healthy controls.[9] Here, we report HTG post-COVID presenting with AP. Although there is still not much evidence to recommend screening all COVID patients for lipid abnormalities, this may be beneficial in high-risk groups like diabetics. Early management of elevated lipids in such patients may help prevent complications such as pancreatitis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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