Acute pancreatitis and COVID-19: a new target for infection?

Balthazar, Júlia Aith; Chehter, Ethel Zimberg

doi:10.31744/einstein_journal/2022RW6667

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

REVIEW • Einstein (São Paulo) 20 • 2022 • https://doi.org/10.31744/einstein_journal/2022RW6667 copy

Acute pancreatitis and COVID-19: a new target for infection?

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

This review aimed to investigate whether SARS-CoV-2 is capable of infecting the gland and causing acute pancreatitis, and the peculiarities in the management of these cases. The research was conducted through PubMed^® database, and 62 articles were systematically selected for analysis. Differences were found in the literature; however, there are important warnings, such as the presence of hyperlipasemia, clinical and imaging findings suggestive of acute pancreatitis in the presence and even in the absence of respiratory symptoms. Attention should be paid to clinical and imaging findings during this virus infection, since it is possible to identify these two diseases early. Therefore, it is possible to detect and isolate these patients more quickly, providing the correct care and decreasing the morbidity and mortality of two potentially severe diseases.

Pancreatitis; Coronavirus infections; COVID-19; SARS-CoV-2; Betacoronavirus

Studies	Type of article	Patients (n)	Age (median)	Amylase/lipase (U/L)	Diagnosis of pancreatitis	Relation between COVID-19 and acute pancreatitis?
Zippi et al.⁽⁷⁾	Review	14	-	-	-	Yes
Suchman et al.⁽¹⁴⁾	Cohort	13	12	Amylase and lipase >3x	INSPPIRE	Yes
Hegyi et al.⁽¹⁵⁾	Meta-analysis	12	-	-	-	Yes
Akarsu et al.⁽¹⁶⁾	Prospective study	316	54	Amylase and lipase >3x	Modified Atlanta Classification	Yes
Gupta⁽¹⁷⁾	Meta-analysis	4	53	Amylase and lipase >3x	-	Yes
Juhász et al.⁽¹⁸⁾	Systematic review	8	-	-	Atlanta Classification	No
McNabb-Baltar et al.⁽¹⁹⁾	Cohort	71	64.9	Lipase >60	Atlanta Classification	No
Miró et al.⁽²⁰⁾	Case-control	54	-	Amylase >3x	Atlanta Classification	No
Lax et al.⁽²¹⁾	Prospective study (autopsy)	11	80.5	-	-	Yes
Rasch et al.⁽²²⁾	Cohort	38	68.5	Mean lipase of 422U/L	Modified Atlanta Classification	No
Inamdar et al.⁽²³⁾	Cohort	32	53.44±16.60	Amylase and lipase >3x	Atlanta Classification	Yes
Dirweesh et al.⁽²⁴⁾	Cohort	14	55.2±14.8	-	Atlanta Classification	Yes
Hanley et al.⁽²⁵⁾	Cohort	8	-	-	Autopsy	Yes
Szatmary et al.⁽²⁶⁾	Cohort	5	42	Median amylasemia of 149U/L	Atlanta Classification	Yes
Gubatan et al.⁽²⁷⁾	Cohort	8	55.3±18.7	-	-	No
Akkus et al.⁽²⁸⁾	Cohort	20	55.5±18.9	Mean lipase of 91U/L	Atlanta Classification	No
Samanta et al.⁽²⁹⁾	Systematic review	5	-	-	-	No
Shiralkar et al.⁽³⁰⁾	Cohort	10	45.1±19.6	-	Abdominal CT and MRI	Yes
Pandanaboyana et al.⁽³¹⁾	Cohort	149	59.9±17.2	Hyperamylasemia	Modified Atlanta Classification	Yes
Goyal et al.⁽³²⁾	Systematic review	7	-	Hyperlipasemia	-	No
Rathi et al.⁽³³⁾	Cohort	83	-	Median lipase of 391U/L	-	No
McGuinness et al.⁽³⁴⁾	Cohort	650	57	Lipase >3x	Atlanta Classification	No
Wang et al.⁽³⁵⁾	Cohort	52	55±15	Median amylase of 115±25U/L Median lipase of 71±34U/L	>90U/L amylase and >70U/L lipase with pancreatic injury	Yes

Article data	Miao et al.⁽⁶⁾	Aloysius et al.⁽³⁶⁾	Anand et al.⁽³⁷⁾	Hadi et al.⁽³⁸⁾	Hadi et al.⁽³⁸⁾	Meireles et al.⁽³⁹⁾
Age	26	36	59	47	68	36
Sex	Female	Female	Female	Female	Female	Female
Past history	-	Obesity and anxiety disorder	Thrombophilia and prior cholecystectomy	-	HTN, hypothyroidism, and osteoporosis	Post-HELLP syndrome, CKD, and HTN
Initial symptoms	Vomiting, epigastric pain, and fever	Fever, dry cough, dyspnea, nausea, vomiting, and diarrhea	Fever, sore throat, and myalgia	Fever, headache, anorexia, sore throat, and dyspnea	Epigastric pain and fever	Dry cough, fever, and dyspnea
GIT symptoms	Yes	Yes	Yes	No	Yes	Yes
Abdominal pain	Epigastric	Band-like epigastric pain irradiating towards the back	-	-	Epigastric	Band-like epigastric pain
Pneumonia	Yes	Yes	Yes	Yes	Yes	Yes
SARS	No	Yes	No	Yes	Yes	Yes
Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR	RT-PCR	?
Amylase, U/L	Not done	325	Not done	>1,500	934	718
Lipase, U/L	430	627	Not done	Not done	Not done	631
CRP, mg/dL	1.38	1.95	6.27	-	7.7	11.9
Imaging test suggestive of acute pancreatitis	Abdominal CT scan	No	Abdominal CT scan	Abdominal ultrasound	No	Abdominal CT scan
Triglycerides, mg/dL	Not done	136	Not done	Normal	Normal	120
Cholelithiasis or alcoholism	No	No	No	No	No	No
Diagnosis of pancreatitis	Imaging, clinical, and laboratory	Modified Atlanta Classification	Suggestive abdominal CT scan	Modified Glasgow Coma Score for Acute Pancreatitis (5 points)	Modified Glasgow Coma Score for Acute Pancreatitis (5 points)	Imaging, clinical, and laboratory
CUM	-	Alprazolam	-	-	Losartan, levothyroxine, alendronate, and cyanocobalamin (Vitamina B12)	Nifedipine and carvedilol
Medication on admission	-	-	-	-	-	-
Complications		NIV	-	OTI and mechanical ventilation, hemodialysis, and ECMO	OTI and mechanical ventilation, and hemodialysis	-
Outcome	Resolution	Resolution	Resolution	Not available	Not available	Resolution

Article data	Shinohara et al.⁽⁴⁰⁾	Meyers et al.⁽⁴¹⁾	Cheung et al.⁽⁴²⁾	Kandasamy et al.⁽⁴³⁾	Lakshmanan et al.⁽⁴⁴⁾

Age	58	67	38	45	68
Sex	Male	Male	Male	Female	Male
Personal antecedents	HTN	HTN and cholecystectomy	-	?	DM, HTN, and CKD
Initial symptoms	Fever and dyspnea	Epigastric pain, fever, tachycardia, and tight abdomen	Fever, intense epigastric pain, nausea, and vomiting	Epigastric pain irradiating towards the back, nausea, and vomiting	Loss of appetite and nausea
GIT symptoms	Yes	Yes	Yes	Yes	Yes
Abdominal pain	-	Epigastric	Epigastric	Epigastric irradiating towards the back	Denies
Pneumonia	Yes	Yes	No	Yes	No
SARS	Yes	No	No	No	No
Article data	Shinohara et al.⁽⁴⁰⁾	Meyers et al.⁽⁴¹⁾	Cheung et al.⁽⁴²⁾	Kandasamy et al.⁽⁴³⁾	Lakshmanan et al.⁽⁴⁴⁾
Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR	RT-PCR
Amylase, U/L	383	Not done	Not done	364	1,030
Lipase, U/L	Not done	5,295	1,219.2	293	2,035
CRP, mg/dL	11.51	Not done	Not done	Not done	15.8
Imaging test suggestive of acute pancreatitis	Abdominal CT scan	Abdominal CT scan	Abdominal CT scan and MRI	Abdominal CT scan	Abdominal CT scan
Triglycerides, mg/dL	Not done	Normal	Normal	Not done	Normal
Cholelithiasis or alcoholism	No	Mild alcoholism	No	No	No
Diagnosis of pancreatitis	Imaging, clinical, and laboratory	Abdominal CT	Abdominal CT	Abdominal CT	Imaging, clinical, and laboratory
CUM	-	-	-	-	-
Medication on admission	Piperacillin- tazobactam, azithromycin, favipiravir, nafamostat mesilate, and methylprednisolone	-	-	Empirical antibiotic	Empirical antibiotic
Complications	OTI and ECMO	Not available	-	NIV	-
Outcome	Resolution	Not available	Resolution	Resolution	Resolution

Article data	Gonzalo-Voltas et al.⁽⁴⁵⁾	Brikman et al.⁽⁴⁶⁾	Narang et al.⁽⁴⁷⁾	Wang et al.⁽⁴⁸⁾	Wang et al.⁽⁴⁸⁾

Age	76	61	20	42	35
Sex	Female	Male	Female	Male	Male
Past history	Hypercholesterolemia and GERD	-	Primigesta, 33- week gestation, obesity, and cholecystectomy	-	-
Initial symptoms	Epigastric pain and vomiting	Fever, dyspnea, and cough	Dry cough and myalgia	Nausea and epigastic pain	Abdominal pain, nausea, and vomiting
GIT symptoms	Yes	Yes	Yes	Yes	Yes
Abdominal pain	Band-like epigastric pain	Diffuse abdominal pain	Epigastric pain irradiating to the back	Epigastric pain irradiating to the back	Epigastric pain irradiating to the back
Pneumonia	No	Yes	Yes	Yes	Yes
SARS	No	Yes	Yes	Yes	No
Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR	RT-PCR
Amylase, U/L	3,568	142	1,168	132	Normal
Lipase, U/L	Not done	203	859	382	1,042
CPR, mg/dL	1.9	-	-	>20	>20
Imaging test suggestive of acute pancreatitis	Abdominal CT and ultrasound	Abdominal CT	Abdominal CT	-	Abdominal CT
Triglycerides, mg/dL	Not done	281.67	-	283.44	170.06
Cholelithiasis or alcoholism	No	No	No	No	No
Diagnosis of pancreatitis	Imaging, clinical, and laboratory	Modified Atlanta Classification	Presumptive	Ranson	Imaging, clinical, and laboratory
CUM	Omeprazole 20mg/day	-	-	-	-

Article data	Gonzalo-Voltas et al.⁽⁴⁵⁾	Brikman et al.⁽⁴⁶⁾	Narang et al.⁽⁴⁷⁾	Wang et al.⁽⁴⁸⁾	Wang et al.⁽⁴⁸⁾

Medication on admission	Azithromycin, chloroquine, lopinavir, and ritonavir	Azithromycin, hydroxychloroquine, zinc, tocilizumabe, dexamethasone, enoxaparin, lopinavir- ritonavir, pantoprazole, ciprofloxacin, and clindamycin	-	-	-
Complications	-	NIV	NIV and premature rupture of membranes, and preterm birth	Cardiac arrest, OTI and mechanical ventilation, and hemodialysis	-
Outcome	Resolution	Resolution	Resolution	Death	Resolution

Article data	Tollard et al.⁽⁴⁹⁾	Acherjya et al.⁽⁵⁰⁾	Karimzadeh et al.⁽⁵¹⁾	Simou et al.⁽⁵²⁾	Mazrouei et al.⁽⁵³⁾

Age	32	57	65	67	24
Sex	Female	Female	Female	?	Male
Past history	Morbid obesity and diabetic ketoacidosis	HTN, type 2 DM, breast and larynx cancer, and prior cholecystectomy	HTN and asthma	Type 2 DM, obesity, and prior cholecystectomy	-
Initial symptoms	Dyspnea, polyuria, polydipsia, and abdominal pain	High fever, myalgia, anosmia, fatigue, and arthralgia	Epigastric pain, nausea, chills, and myalgia. On the 7^th day, the patient presented with dyspnea	Fever, dyspnea, myalgia, and arthralgia	Epigastric pain, nausea, vomiting, and mild respiratory symptoms
GIT symptoms	Yes	Yes	Yes	No	Yes
Abdominal pain	Abdominal	Epigastric pain irradiating to the back	Epigastric	No	Epigastric
Pneumonia	Yes	Yes	Yes	Yes	No
SARS		No	No	No	No
Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR	RT-PCR
Amylase, U/L	Not done	Not done	192	-	391
Lipase, U/L	321	8,352	283	576	578
CRP, mg/dL	-	25.2	-	4.13	-
Imaging test suggestive of acute pancreatitis	Abdominal CT scan	Abdominal CT scan	Abdominal CT scan	Abdominal CT scan	Abdominal CT scan
Triglycerides, mg/dL	Normal	276	80	212.58	Not done
Cholelithiasis or alcoholism	No	No	No	No	No
Diagnosis of pancreatitis	Imaging, clinical, and laboratory	Atlanta Classification	Clinical	Balthazar Classification of Abdominal CT	Atlanta Classification
CUM	-	Radiation therapy, trastuzumab, losartan, metformin, and insulin	-	-	-
Medication on admission	-	Favipiravir and enoxaparin in prophylactic dose	Levofloxacin, ondansetron, oseltamivir, hydroxychloroquine, ribavirin, lopinavir, ritonavir, vancomycin, cefepime, and oxygen therapy	Oxygen therapy, hydroxychloroquine, azithromycin, methylprednisolone, vitamin C, zinc, and enoxaparin	-
Complications	Diabetic ketoacidosis, pulmonary thromboembolism, OTI and mechanical ventilation, and distributive shock	NIV	NIV	NIV	-
Outcome	Death	Resolution	Resolution	Death	Resolution

Article data	Kumaran et al.⁽⁵⁴⁾	Kataria et al.⁽⁵⁵⁾	AlHarmi et al.⁽⁵⁶⁾	Alwaeli et al.⁽⁵⁷⁾

Age	67	46	52	30
Sex	Female	Female	Female	Male
Past history	Laparotomy with intestinal resection for stenosis of the mesenteric artery, and secondary prophylaxis of thrombosis	-	Type 2 DM, HTN, hypothyroidism, and morbid obesity	-
Initial symptoms	Epigastric pain, diarrhea, and vomiting	Fever, dry cough, and dyspnea	Fever, dry cough, and dyspnea	Fever, dry cough, nausea, vomiting, abdominal pain, diarrhea, and progressive dyspnea
GIT symptoms	Yes	Yes	Yes	Yes
Abdominal pain	Epigastric	Epigastric pain irradiating to the back	Abdominal	Epigastric pain irradiating to the back
Pneumonia	No	Yes	Yes	Yes
SARS	No	Yes	Yes	Yes
Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR
Amylase, U/L	1,483	501	47	151
Lipase, U/L	Not done	1,541		1,022
CPR, mg/dL	15.8	2.51	1.09	-
Imaging test suggestive of acute pancreatitis	Abdominal CT	Abdominal CT	Abdominal CT	Abdominal CT
Triglycerides, mg/dL	310	153	168.3	133
Cholelithiasis or alcoholism	No	No	No	No
Diagnosis of pancreatitis	Modified Atlanta Classification	Imaging, clinical, and laboratory	Imaging and clinical	Imaging, clinical, and laboratory
CUM	-	-	-	-
Medication on admission	Meropenem, metronidazole, and clyndamycin	Azithromycin, ceftriaxone, and oxygen therapy	Dexamethasone, methylprednisolone, ceftriaxone, doxycycline, azithromycin, enoxaparin, vitamin D, zinc, fluticasone, salbutamol, ipratropium, and pantoprazole	-
Complications	NIV	NIV	NIV	OTI and mechanical ventilation
Outcome	Resolution	Resolution	Resolution	Resolution

Article data	Alves et al.⁽⁵⁸⁾	Fernandes et al.⁽⁵⁹⁾	Purayil et al.⁽⁶⁰⁾	Patnaik et al.⁽⁶¹⁾	Rabice et al.⁽⁶²⁾

Age	56	36	58	29	36
Sex	Female	Female	Male	Male	Female
Past history		-	-	-	G4PC2 33-week gestation, obesity, pre-eclampsia, type 1 DM, and prior cholecystectomy
Initial symptoms	Dry cough, dyspnea, malaise, and abdominal pain	Fever, headache, and dyspnea	Fever, vomiting, and epigastric pain	Diffuse abdominal pain, irradiating to the back, fever, and dyspnea	Cough and fever
GIT symptoms	Yes	Yes	Yes	Yes	Yes
Abdominal pain	Epigastric	Epigastric	Epigastric	Diffuse, irradiating to the back	Abdominal
Pneumonia	Yes	Yes	Yes	Yes	Yes
SARS	Yes	No	No		No

Article data	Alves et al.⁽⁵⁸⁾	Fernandes et al.⁽⁵⁹⁾	Purayil et al.⁽⁶⁰⁾	Patnaik et al.⁽⁶¹⁾	Rabice et al.⁽⁶²⁾

Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR	RT-PCR
Amylase, U/L	544	710	249	2,861	88
Lipase, U/L	2,993	640	>600	1,650	875
CRP, mg/dL	-	-	29	14.6	-
Imaging test suggestive of acute pancreatitis	Abdominal CT	Abdominal CT	No	Abdominal CT	No
Triglycerides, mg/dL	Not done	Not done	Normal	84	210
Cholelithiasis or alcoholism	No	No	No	No	No
Diagnosis of pancreatitis	Imaging, clinical, and laboratory	Imaging, clinical, and laboratory	Clinical and laboratory	Imaging, clinical, and laboratory	Clinical and laboratory
CUM	-	-	-	-	-
Medication on admission	-	-	Azithromycin and hydroxychloroquine	Meropenem and support	Dicloxacillin
Complications	OTI and mechanical ventilation	-	-	-	NIV and Caesarean section
Outcome	Resolution	Resolution	Resolution	Resolution	Resolution

Article data	Bokhari et al.⁽⁶³⁾	Samies et al.⁽⁶⁴⁾	Samies et al.⁽⁶⁴⁾	Samies et al.⁽⁶⁴⁾	Kurihara et al.⁽⁶⁵⁾

Age	32	15	11	16	55
Sex	Male	Male	Male	Female	Male
Past history	-	Obesity	Overweight	Prior pancreatitis	-
Initial symptoms	Fever, sore throat, productive cough, myalgia, and diarrhea	Vomiting, epigastric pain, fever, ageusia, and anosmia	Abdominal pain, headache, chills, intermittent hematochezia, and epistaxis	Nausea and epigastric abdominal pain	Pneumonia
GIT symptoms	Yes	Yes	Yes	Yes	? - sedated patient
Abdominal pain	Epigastric irradiated to the back	Epigastric	Periumbilical	Epigastric irradiating to the back	? - sedated patient
Pneumonia	Yes	Yes	Yes	No	Yes
SARS	No		No	No	Yes
Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR	RT-PCR
Amylase, U/L	672	Not done	215	Not done	252
Lipase, U/L	721	233	953	1,909	263
CPR, mg/dL	1.58	1.47	24.11	Not done	8.53
Imaging tests suggestive of acute pancreatitis	Abdominal CT	Abdominal CT	Abdominal CT	Abdominal ultrasound	Abdominal CT
Triglycerides, mg/dL	150	Not done	Not done	Not done	185
Cholelithiasis or alcoholism	No	No	No	Yes	No
Diagnosis of pancreatitis	Imaging, clinical, and laboratory	Imaging, clinical, and laboratory	Clinical and laboratory	Clinical and laboratory	Imaging, clinical, and laboratory
CUM	-	-	-	-	-
Medication on admission	-	-	Piperacillin-tazobactam	-	Lopinavir-ritonavir, azithromycin, and ceftriaxone
Complications	-	-	Acute appendicitis	-	OTI and mechanical ventilation, ECMO, and hemodialysis
Outcome	Resolution	Resolution	Resolution	Resolution	Resolution

Article data	Bineshfar et al.⁽⁶⁶⁾	Hassani et al.⁽⁶⁷⁾	Bouali et al.⁽⁶⁸⁾	Schepis et al.⁽⁶⁹⁾	Ahmed et al.⁽⁷⁰⁾

Age	14	78	60	67	47
Sex	Male	Female	Female	Female	Male
Past history	-	HTN and ischemic heart disease	-	-	-
Initial symptoms	Abdominal pain, nausea, and vomiting	Positional epigastric pain, nausea, and vomiting	Respiratory failure, diffuse abdominal pain, hematemesis, and melena	Fever, epigastric pain, and vomiting	Fever, sore throat, left-sided cervical edema, fatigue, and myalgia
GIT symptoms	Yes	Yes	Yes	Yes	Yes
Abdominal pain	Abdominal	Positional epigastric	Diffuse	Epigastric	Diffuse/RIF
Pneumonia	No	Yes	No	Yes	Yes
SARS	No	Yes	No	No	No
Test to confirm COVID-19	RT-PCR	RT-PCR	RT-PCR	RT-PCR	RT-PCR
Amylase, U/L	1,914	1,200	-	Normal	349
Lipase, U/L	Not done	1,450	627	Normal	>600
CRP, mg/dL	4	-	8	Increased	2.51
Imaging test suggestive of acute pancreatitis	Abdominal CT	Abdominal ultrasound	Abdominal CT	Abdominal CT	Abdominal CT
Triglycerides, mg/dL	Not done	Normal	Not done	Not done	Not done
Cholelithiasis or alcoholism	No	No	No	No	No
Diagnosis of pancreatitis	Atlanta Classification	Imaging, clinical, and laboratory	Balthazar Classification of abdominal CT	Analysis of pancreatic pseudocyst fluid containing SARS-CoV-2 RNA	Clinical and laboratory
CUM	-	Valsartan, clopidogrel, ASA, and atorvastatin	-	-	-
Medication on admission	-	Remdesivir and interferon beta-1b	-	-	Hydroxychloroquine, azithromycin, and cefuroxime
Complications	-	OTI and mechanical ventilation, kidney failure, and cardiorespiratory arrest	Laparotomy, gastrectomy, and cardiorespiratory arrest	Drainage of pancreatic pseudocyst	-
Outcome	Resolution	Death	Death	Resolution	Resolution

Article data	Dietrich et al.⁽⁷¹⁾	Chivato et al.⁽⁷²⁾	...Continuation Table 2. Key dat ...Continuation Table 2. Key data from the case reports a from the case reports	...Continuation Table 2. Key data from the case reports	...Continuation Table 2. Key data from the case reports

Age		72		55
Sex		Male		Male
Past history		Overweight and HTN		-
Initial symptoms		Nausea and mild abdominal pain		Respiratory failure
GIT symptoms		Yes		-
Abdominal pain		Mild		-
Pneumonia		Yes		Yes
SARS		Yes		Yes
Test to confirm COVID-19		RT-PCR		RT-PCR
Amylase, U/L		Not done		Increased

Article data		Dietrich et al.⁽⁷¹⁾		Chivato et al.⁽⁷²⁾

Lipase, U/L		185		Not done
CRP, mg/dL		2.3		-
Imaging test suggestive of acute pancreatitis		Abdominal ultrasound		Abdominal CT
Triglycerides, mg/dL		Not done		Normal
Cholelithiasis or alcoholism		Cholelithiasis, without cholestasis		Normal
Diagnosis of pancreatitis		Imaging, clinical, and laboratory		Imaging and laboratorial
CUM		Beta-blocker		-
Medication on admission		Ceftriaxone and clarithromycin		Hydroxychloroquine, lopinavir, azithromycin, and methylprednisolone
Complications		OTI and mechanical ventilation		Not available
Outcome		Resolution		Resolution

	Mean 46.47 and median 47
Sex	22 female, 19 male, and one unknown
Comorbidities, %	47.62
Abdominal pain, %	83.33
Pneumonia, %	80.95
SARS, %	38.1
Amylase mean, U/L	779.25
Lipase, U/L	1,230.88 2
C-reactive protein mean, mg/dL	9.73
Imaging suggestive of pancreatitis, %	85.71
Diagnostic classification as per Atlanta, %	73.8 (31/42)
Complications, %*	52.38
Outcome, %*	80.95 in recovery and 11.9 deaths

Instituto Israelita de Ensino e Pesquisa Albert Einstein Avenida Albert Einstein, 627/701 , 05651-901 São Paulo - SP, Tel.: (55 11) 2151 0904 - São Paulo - SP - Brazil
E-mail: revista@einstein.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Corresponding author: Júlia Aith Balthazar Avenida Príncipe de Gales, 821, Portaria 1 – Vila Príncipe de Gales Zip code: 09060-650 – Santo André, SP, Brazil Phone: (55 11) 4993-5400 E-mail: juliaith@gmail.com