Hyperlipidemia, COVID-19 and acute pancreatitis: A tale of three entities

COVID-19-Induced Hypertriglyceridemia Leading to Pancreatitis in a 51-Year-Old Female

There are increasing reports of the effects of COVID-19 on the pancreas. Pancreatitis, as a result of hypertriglyceridemia, has also been reported. Hypothesized mechanisms include hemophagocytic lymphohistiocytosis (HLH) syndrome and acquired lipoprotein lipase (LPL) inhibitors. We present a 51-year-old female patient who presented with nausea, vomiting, and epigastric abdominal pain radiating to the back. On examination, she had generalized abdominal tenderness without guarding or rebound tenderness. Our workup revealed elevated lipase of 1150 units/L, triglycerides (TG) of 11340 mg/dL, and mild pancreatitis on an abdominal computed tomography (CT) scan. On day 2, she developed a new oxygen requirement and tested positive for COVID-19. She was treated with fluids and opiates for pancreatitis, plasmapheresis, and an insulin infusion to treat her hypertriglyceridemia. She was treated with remdesivir for an acute COVID-19 infection. Triglycerides decreased to <500 mg/dL with treatment, and she was discharged home on oral lipid-lowering agents. By discussing this case, we aim to shed light on the association between COVID-19 and hypertriglyceridemia, which can further lead to life-threatening complications such as acute pancreatitis. Further studies are needed to identify the exact mechanisms, preventive measures, and long-term effects of COVID-19 on triglycerides and the pancreas.

Microbial Fermentation Enhances the Effect of Black Tea on Hyperlipidemia by Mediating Bile Acid Metabolism and Remodeling Intestinal Microbes

Black tea (BT), the most consumed tea worldwide, can alleviate hyperlipidemia which is a serious threat to human health. However, the quality of summer BT is poor. It was improved by microbial fermentation in a previous study, but whether it affects hypolipidemic activity is unknown. Therefore, we compared the hypolipidemic activity of BT and microbially fermented black tea (EFT). The results demonstrated that BT inhibited weight gain and improved lipid and total bile acid (TBA) levels, and microbial fermentation reinforced this activity. Mechanistically, both BT and EFT mediate bile acid circulation to relieve hyperlipidemia. In addition, BT and EFT improve dyslipidemia by modifying the gut microbiota. Specifically, the increase in Lactobacillus johnsonii by BT, and the increase in Mucispirillum and Colidextribacter by EFT may also be potential causes for alleviation of hyperlipidemia. In summary, we demonstrated that microbial fermentation strengthened the hypolipidemic activity of BT and increased the added value of BT.

COVID-19-associated hypertriglyceridemia and impact of treatment

Background

Coronavirus disease 2019 (COVID-19) associated hypertriglyceridemia was observed among patients admitted to intensive care units (ICU) in Qatar. This study aimed to describe COVID-19-associated-hypertriglyceridemia in ICU patients and the impact of treating hypertriglyceridemia on clinical outcomes.

Methods

A retrospective observational cohort study of adult patients who were admitted to the ICU with a confirmed diagnosis of COVID-19 pneumonia according to the World Health Organization criteria. Hypertriglyceridemia was defined as triglyceride level of 1.7 mmol/L (≥150 mg/dL) and severe hypertriglyceridemia as fasting TG of ≥5.6 mmol/L (≥500 mg/dL).

Results

Of 1,234 enrolled patients, 1,016 (82.3%) had hypertriglyceridemia. Median age was 50 years and 87.9% were males. Patients with hypertriglyceridemia showed significantly longer time to COVID-19 recovery, ICU and hospital stay, and time to death (29.3 vs. 16.9 days) without a difference in mortality between groups. Of patients with hypertriglyceridemia, 343 (33.8%) received treatment (i.e., fibrate and/or omega-3). Patients in treatment group showed longer time to COVID-19 recovery and hospital stay with no difference in death rates in comparison with those in no-treatment group. Relatively older patients were less likely to experience hypertriglyceridemia (odd ratio (OR) 0.976; 95% CI: 0.956, 0.995) or to receive treatment (OR 0.977; 95% CI: 0.960, 0.994). Whereas patients who received tocilizumab were more likely to experience high TG level (OR 3.508; 95% CI: 2.046, 6.015) and to receive treatment for it (OR 2.528; 95% CI: 1.628, 3.926).

Conclusion

Hypertriglyceridemia associated with COVID-19 did not increase death rate, but prolonged time to death and length of stay. Treating hypertriglyceridemia did not translate into improvement in clinical outcomes including mortality.

The Pancreas in Coronavirus Disease 2019 Infection

An association between acute pancreatitis (AP) and coronavirus disease 2019 (COVID-19) has been proposed but the mechanisms of pancreatic injury of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and the implicative role on the development of AP are not yet fully understood. COVID-19 also imposed major challenges on pancreatic cancer management. We conducted an analysis on the mechanisms of pancreatic injury by SARS-CoV-2 and reviewed published case reports of AP attributed to COVID-19. We also examined the pandemic effect on pancreatic cancer diagnosis and management, including pancreatic surgery.

Surgical intervention for acute pancreatitis in the COVID-19 era

Approximately 15%-19% of patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infections develop gastrointestinal symptoms. Acute pancreatitis (AP) has been reported in 0.1% of patients with coronavirus disease 2019 (COVID-19). Biliary AP was most common (78.4%) before the COVID-19 pandemic; idiopathic AP is most common in patients with COVID-19 (up to 57.1%). The number of emergency department presentations decreased by 23.3% during the pandemic and many governments made national recommendations to delay nonurgent endoscopic procedures, leading to decrements of 22% in combined esophagogastroduodenoscopy (EGD) and colonoscopy and 20% in EGD after the COVID-19 pandemic. The symptoms and signs of COVID-19-related AP are fever (63%), abdominal pain (58%), respiratory symptoms (40%), nausea and vomiting (39%), and headache (4%). Approximately 5-10% of patients develop necrotizing or hemorrhagic AP, and patients who required surgical intervention had a higher mortality risk. Compared to 2019, the rates of elective surgery decreased by 41.8% in 2020; including cholecystectomy (40.1% decrease) and pancreas (111.1% decrease). Surgical volumes also decreased by 18.7% in 2020; device-assisted laparoscopic and robot-assisted procedures reduced by 45.4% and 61.9% during the COVID-19 Lockdown in 2020.