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\title{A case of acute necrotising pancreatitis following the second dose of
Pfizer-BioNTech COVID-19 mRNA vaccine}



\author[1]{Talia Walter}%
\author[1]{Saxon Connor}%
\author[1]{Catherine Stedman}%
\author[2]{Matthew Doogue}%
\affil[1]{Canterbury District Health Board}%
\affil[2]{University of Otago}%


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  \date{June 18, 2024}


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\textbf{A case of acute necrotising pancreatitis following the second
dose of Pfizer-BioNTech COVID-19 mRNA vaccine}

As of 22 June 2021, there have been about 400,000,000 doses of the
Pfizer-BioNTech COVID-19 mRNA vaccine administered world-wide. At this
time, 176 cases of pancreatitis have been reported in pharmacovigilance
reports submitted to the WHO.\textsuperscript{1} No epidemiological link
between the Pfizer-BioNTech COVID-19 mRNA vaccine and pancreatitis has
been reported. We report a case of acute necrotising pancreatitis
following the second dose of the Pfizer-BioNTech COVID-19 mRNA vaccine.
This case has been reported to the New Zealand Pharmacovigilance Centre
and the patient has consented to publication of the case report.

A 43-year-old, NZ European male was diagnosed with acute necrotising
pancreatitis 10 hours following the administration of his second
Pfizer-BioNTech COVID-19 mRNA vaccine. He has a background of atopy with
seasonal rhinitis, eczema and asthma, all of which are `mild'. He takes
no regular medications and takes as needed melatonin 2 mg nocte,
cetirizine 10 mg for hay fever, and betamethasone and emollient cream
for dermatitis. He has no family history of note and works in a senior
professional role. He drinks six standard units of alcohol per week, has
never been a tobacco smoker and does not use recreational drugs -- and
his employer undertakes regular drug testing.

He had a previous episode of pancreatitis in 2011, precipitated by high
alcohol intake during a holiday abroad. He is otherwise previously well.
There is no family history of note, his father was a smoker and died of
lung cancer in his 60s, his mother is well, he has two siblings and
three children all of whom are well. He is not aware of any diseases of
note in his extended family.

In May 2021 he received his second dose of Pfizer-BioNTech COVID-19 mRNA
vaccine, he was well at that time. Four hours after the dose he had two
330ml bottles of 5\% alcohol beer with his dinner. Six hours after the
dose he became unwell with nausea, epigastric pain, and vomiting. Ten
hours after the dose blood tests on admission to hospital included:
white cell count 18.5 x10\textsuperscript{9}/L (4 - 11), neutrophils
15.5 x10\textsuperscript{9}/L (1.9 - 7.5), lymphocytes 0.8
x10\textsuperscript{9}/L (1.0 - 4.0), CRP \textless{}3 mg/L
(\textless{}5), lipase 23,750 U/L (10 -- 70), and triglycerides 3.3
mmol/L. Acute pancreatitis was diagnosed. An ultrasound scan showed
pancreatitis without evidence of cholelithiasis. He subsequently
deteriorated and a computer tomography (CT) scan on 17 May, day 9 of the
illness, showed severe necrotising pancreatitis with collections.

During the admission under a specialist hepatobiliary surgical team,
known causes of pancreatitis were excluded including: steroid use,
trauma, family history of autoimmune conditions, and infection. He did
not have the risk factors of obesity, smoking or heavy alcohol
consumption. He had the risk factor of a previous episode of acute
pancreatitis. The incidence of pancreatitis in New Zealand Europeans in
this age group is approximately 50 per 100,000 per
year.\textsuperscript{2} Idiopathic cases represent about 15\% of these.

Using the Naranjo criteria, the pancreatitis being 'caused' by the
Pfizer-BioNTech COVID-19 mRNA vaccine score was 6
`probable'.\textsuperscript{3} Clinical case discussion (including a
hepatobiliary surgeon, gastroenterologist and clinical pharmacologist)
concluded that while idiopathic pancreatitis could not be excluded, the
onset of symptoms and findings were consistent with an acute
precipitating event around the time the second vaccine dose was
administered.

In addition to the 176 cases reported in VigiBase, searches of PubMed
and Google Scholar identified two published case reports of
pancreatitis following the Pfizer-BioNTech COVID-19 mRNA vaccine. These
were following administration of the first dose of the Pfizer-BioNTech
COVID-19 mRNA vaccine. In one case symptoms developed several hours
after vaccine administration and the other several days after vaccine
administration.\textsuperscript{4,5}

Acute pancreatitis is a rare in patients with COVID-19 but
characteristic patterns of illness have been
reported.\textsuperscript{6} This raises the possibility that an immune
response to either the virus or the vaccine could have common sequalae.

This case of acute pancreatitis was temporally associated with the
Pfizer-BioNTech COVID-19 mRNA vaccine suggesting a causal link. The
characteristics of pancreatitis cases associated with the
Pfizer-BioNTech COVID-19 mRNA vaccine should be examined to see if a
consistent pattern is present.

\begin{enumerate}
\tightlist
\item
  VigiAccess http://www.vigiaccess.org/ - accessed June 24, 2021.
\item
  Pendharkar SA, Mathew J, Zhao J, Windsor JA, Exeter J, Petrov MS.
  Ethnic and geographic variations in the incidence of pancreatitis and
  post- pancreatitis diabetes mellitus in New Zealand: a nationwide
  population- based study. 2017;130(1450):14.
\item
  Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the
  probability of adverse drug reactions. \emph{Clin Pharmacol Ther} .
  1981;30(2):239-245. doi:10.1038/clpt.1981.154
\item
  Cie\selectlanguage{polish}ś\selectlanguage{english}lewicz A, Dudek M, Krela-Ka\selectlanguage{polish}ź\selectlanguage{english}mierczak I, Jab\selectlanguage{polish}ł\selectlanguage{english}ecka A, Lesiak M,
  Korzeniowska K. Pancreatic Injury after COVID-19 Vaccine---A Case
  Report. \emph{Vaccines} . 2021;9(6):576. doi:10.3390/vaccines9060576
\item
  Parkash O, Sharko A, Farooqi A, Ying GW, Sura P. Acute Pancreatitis: A
  Possible Side Effect of COVID-19 Vaccine. \emph{Cureus} . Published
  online April 28, 2021. doi:10.7759/cureus.14741
\item
  Bircakova B, Bruha R, Lambert L, Grusova G, Michalek P, Burgetova A. A
  bimodal pattern of the onset of COVID-19 related acute pancreatitis
  supports both the cytotoxic and immune-related pathogenesis -- a
  systematic review. \emph{Scand J Gastroenterol} . 2021;56(7):870-873.
  doi:10.1080/00365521.2021.1922751
\end{enumerate}

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