Case 1
A 62-years old male patient, complaining of severe abdominal pain radiating to the back and vomiting in the last 4 days, was admitted to the Emergency Unit. At entry, body temperature 36,6°C, blood pressure 135/85 mm Hg, heart rate 88 bpm, and oxygen saturation 94% at room air. Laboratory tests showed normal blood count and no signs of cholestasis, whilst an increase of C-reacting protein (12 mg/L; n. v. < 8 mg/L) and ESR 27 (mm/h; n. v. 1-19 mm/h), with a 4-fold increased levels of both amylase (534 U/L – n. v. 25-125 U/L) and lipase (326 U/L – n. v. 8-78 U/L). Abdominal ultra-sonography (US) showed pancreatic enlargement with multiple peri-pancreatic fluid collection in the body-tail area, normal bile ducts, and absence of biliary stones.
The real time polymerase chain reaction (RT-PCR) nasopharyngeal swab resulted positive for CoViD-19 and chest X-ray was negative without respiratory symptoms. The patient was admitted in CoViD Unit with diagnosis of AP in asymptomatic CoViD patient, and standard treatment for AP (fluid replacement, optimization of electrolyte balance) was started, requiring any treatment for his CoViD-19 infection. The medical history did not reveal potential aetiologias of AP.
Following 6 days, the patient developed acute symptoms with worsening abdominal pain, fever (39,8°C), chills, marked increase of ESR (85 mm/h) and C-reactive protein (215 mg/l), and leucocytosis (WBC 26.000 x 103/UL; n. v. 4,8-10,8 x 103/UL). The abdominal CT scan showed a large pancreatic pseudocyst (PP) (17x8x12 cm) developing in the anterior pancreatic body-tail area. Due to the development of recurrent, bulging vomiting, we decided, on the hospital day 9, to perform an endoscopic ultrasound-guided trans-gastric drainage of the pseudocyst and a Hot Axios 15 mm stent (Boston Scientific, Marlborough, MA, USA) was successfully placed (Figure 1A). Before the endoscopic procedure, the pseudocyst fluid sample was collected and the presence of Covid-19 confirmed by RT-PCR analysis with both AllplexTM 2019-nCoV (Seegene, Arrow Diagnostics, South Korea) and Quanty Covid-19 (Clonit, Italy) assays 2.
Two weeks after stent placement, the pancreatic pathology recovered (Figure 1B). Following 2 negative molecular swabs, the patient was discharged from the hospital at day 26, with a planned US for stent removal.