A Rare Case of Viral Pancreatitis as a Result of COVID19 Complicated with Acute Onset Diabetes Mellitus and Severe Diabetic Ketoacidosis

Introduction:COVID-19 have been associated with various systemic manifestations, among which is gastrointestinal manifestations. Pancreatic injury is a rare finding in the course of the disease, therefore we present a case of case of 46 years old female who developed viral pancreatitis secondary to COVID-19, complicated with new onset diabetes mellitus (DM) and severe diabetic ketoacidosis (DKA), an association that was never reported before in literature.Case presentation:We present a 46 years old female with no past medical history who presented to hospital with respiratory distress and altered mental status. Patient presentation complicated with cardiopulmonary arrest, requiring intubation and CPR. Examination revealed tachycardia (105/min), hypotension (82/45) and hypothermia (32.3), obesity (BMI 38), bilateral rhonchi, soft abdomen with negative Collens and Grey-turner signs. Laboratory testing was remarkable for leukocytosis with neutrophilic predominance (17.5 x10(3)/mcL), hyperkalemia (6.6 mmol/L), elevated lipase levels (4248U/L), high-anion gab metabolic acidosis (anion gab 35, arterial pH <7.000), lactatemia, ketosis, negative alcohol screen. CXR showed bilateral dense alveolar infiltrate with peripheral distribution. CT abdomen (Figure-1) showed swelling of the pancreatic tail and fluid at the anterior pararenal space on the left side suggestive of acute pancreatitis. Ultrasound scan was negative for gallbladder stones. CT brain obtained to investigate cause of altered mental status, and was remarkable for 2.5mm intraparenchymal hemorrhage of the right cerebellar hemisphere. Patient was admitted to MICU for management of ARDS secondary to SARS-CoV-19, acute pancreatitis secondary to SARS-CoV-19, severe DKA, intraparenchymal hemorrhage and post cardiac arrest management. Patient expired after 3 days MICU course as result of multi-organ failure. Discussion: Viral pancreatitis is mainly associated with Mumps, Measles, Coxacki, EBV and Hepatitis A virus [2]. In our case, there were no clinical suspicions or laboratory evidence to attribute patient condition for the before-mentioned viruses. The association of both conditions and the absence of other causes of AP support the theory of COVID19-induced pancreatitis in this scenario. AP as a presenting scenario of COVID19 have been rarely reported before [4]. SARS-CoV is known to be associated with development of acute type 1 diabetes milletus, secondary to islets damage in the exocrine and endocrine tissues of the pancreas which express ACE2, this can explains the acute presentation of hyperglycemia and severe diabetic ketoacidosis in our patient who had no past medical history of diabetes. Such phenomena were never reported to be associated with SARS-CoV-2 in literature prior to this report.