University of South Florida Moffitt Cancer Center Tampa, FL, United States
Award: Presidential Poster Award
Amaninder Dhaliwal, MD1, Pratik Patel, MD2, Banreet Dhindsa, MD3, Rene Gomez Esquivel, MD1 1University of South Florida Moffitt Cancer Center, Tampa, FL; 2University of South Florida, Titusville, FL; 3University of Nebraska Medical Center, Omaha, NE
Introduction: The hypothesis involving the pathophysiology of liver damage in COVID-19 infected patients involves the binding of the virus to angiotensin converting enzyme 2 (ACE2) receptors which are found in hepatocytes and hepatic cholangiocytes and increase in interleukin-6 (IL-6) levels resulting in cholestasis. We present a case of cholestatic hepatitis as a result of biliary cast syndrome after acute COVID-19 infection
Case Description/Methods: 42-year-old female with a history of orthotopic heart transplant (2014) on chronic immunosuppression presented with chief complaints of nausea, vomiting and pruritus. Patient had an admission six weeks prior for acute respiratory distress syndrome secondary to COVID-19 infection and was treated with convalescent plasma and Tocilizumab. Liver enzymes during that admission peaked at AST 196, ALT 236, ALP 344, and total bilirubin 1.3, however, they all returned to normal by discharge. These abnormalities were attributed to severe sepsis from COVID-19 infection. Computed Tomography (CT) of the abdomen during that admission revealed normal hepatobiliary anatomy. On this admission, laboratory work up was significant for AST 94, ALT 83, ALP 1003 and total bilirubin of 4.6. Magnetic resonance cholangiopancreatography (MRCP) revealed mild intrahepatic biliary ductal dilation with subtle central biliary enhancement concerning for cholangitis along with hypodense material in extrahepatic biliary system. Endoscopic retrograde cholangiopancreatography (ERCP) with liberal sphincterotomy revealed filling defects on cholangiogram. The biliary tree was swept using a 12-15 mm balloon and patient was found to have multiple large biliary casts, the largest measuring 7 cm. LFTs trended down and she was eventually discharged home in stable condition. She had two more subsequent ERCPs with balloon extraction of multiple small biliary casts from the intrahepatic ducts.
Discussion: Biliary cast syndrome is a well-recognized complication of orthotopic liver transplantation; however, to the best of our knowledge, this is the first case report of biliary cast syndrome secondary to severe COVID-19 infection. As the pathogenesis of COVID-19 becomes better understood, cholestasis with possible biliary cast syndrome should be considered as a potential complication of the COVID-19 virus in a patient with abnormal LFTs, especially after a severe infection.
Figure: Biliary cast
Disclosures: Amaninder Dhaliwal indicated no relevant financial relationships. Pratik Patel indicated no relevant financial relationships. Banreet Dhindsa indicated no relevant financial relationships. Rene Gomez Esquivel indicated no relevant financial relationships.
Amaninder Dhaliwal, MD1, Pratik Patel, MD2, Banreet Dhindsa, MD3, Rene Gomez Esquivel, MD1. P0045 - COVID Bile Duct: Biliary Cast Syndrome as a Complication of SARS-CoV-2 Infection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.