Elevated pancreatic enzyme level in covid-19 patients: Is it a silent bystander

ABSTRACT

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) is a known respiratory pathogen, its impact on other organs including the pancreas has been reported. Only case reports and few retrospective studies have linked coronavirus disease 2019 (COVID-19) to acute pancreatitis (AP) and pancreatic injury (PI). Aims & Methods: This prospective study was planned to look at the incidence of PI in COVID-19 positive patients and its implications. All consecutive patients of established COVID-19 positive cases presenting to a tertiary care center in India between July and October 2020 were assessed. Detailed symptomatology was documented including respiratory and gastrointestinal (GI) symptoms. Prior co-morbidities, drug history and medical history were documented, and patients on pancreatic enzyme level influencing drugs were excluded. All patients, on admission, underwent blood cytology, biochemical parameters and serum inflammatory markers estimation. Pancreatic injury (PI) was defined as any abnormal value of amylase (normal 0-100 U/L) or lipase (normal 0-60 U/L). Patients having clinical AP or any pre-existing GI diseases were excluded. Outcome measures such as need for ICU, oxygen requirement, need for ventilation and mortality were noted. Results: Out of 244 patients screened, 40 were excluded. Of the 203 patients, (128 males;63.1%) studied, 72 (35.5%) had PI. Comparing patients with PI and those without (Table 1) showed that both groups had similar respiratory and/or GI symptoms profile, while asymptomatic cases had less pancreatic enzyme elevation (p=0.035). PI was noted in the older age group (49.83 vs 37.12 yrs., p=0.01) with a male predominance. PI group had a higher proportion of severe disease (29.2% vs 8.4%;p<0.0001) with significantly higher levels of serum ferritin, D-dimer, fibrinogen, procalcitonin and C-reactive protein (CRP) and higher baseline triglyceride (TG) levels. PI group showed higher ICU (p<0.0001), oxygen (p<0.0001) & mechanical ventilation (p=0.003) requirements and mortality (p=0.018). Multivariate regression analysis showed that the severity of the disease was a significant predictor (aOR-4.68;p=0.003) of PI. Diabetes was found to be higher in the PI group (p<0.0001), but not so when adjusted for disease severity. Of all PI patients, 7(3.45%) had enzyme elevation >3 times the upper limit of the normal (ULN), more in severe disease (Severe-4;12.5% vs moderate-2;4% vs mild-1;0.8%, p=0.005). Conclusion: Incidence of PI was seen in more than 1/3rd of the COVID-19 positive patients. PI is not uncommon in COVID-19 patients and is a harbinger of severe disease with greater inflammatory burst and higher intensive care requirement with poorer outcome.