B0028 - A Rare Case of SARS-CoV-2-Induced Cholangiopathy

Severe acute respiratory syndrome coronavirus, a novel coronavirus that was declared a pandemic in 2019 is now known to affect multiple organ systems. While the primary organ affected has been the lungs, as time elapses, this virus finds victims in multiple organ systems. This case describes the clinical course and histopathological findings of a rare SARS-CoV-2 induced cholangiopathy.

A 37-year-old male presented with 5 days of sharp, 10/10, periumbilical pain radiating to the RUQ with no exacerbating or alleviating factors. He had RUQ, and epigastric tenderness to palpation, jaundice and scleral icterus.

Labs showed lipase >3000, total bilirubin 12.5, direct bilirubin 9.6, ALP 281, ALT 144, AST 70, and positive SARS-CoV- 2 PCR. Previous liver chemistries were normal. Autoimmune and viral hepatitis work-up was negative. US was concerning for acute cholecystitis with CBD 9mm. Antibiotics, IVF and morphine were initiated for presumed gallstone pancreatitis/acute cholecystitis/choledocholithiasis. ERCP was pursued due to worsening biliary chemistry despite medical management. It revealed non-dilated CBD, but Mirizzi Syndrome was suspected due to a notably distended gallbladder compressing the common hepatic duct during cholangiogram. Sphincterotomy, sludge removal and biliary stent placement were done. Post-ERCP, ALT, AST, and ALP improved but total bilirubin remained elevated. MRCP failed to reveal intraductal filling defects or abnormalities to suggest sclerosing cholangitis. Cholecystectomy and liver biopsy were done which showed hepatocellular and canalicular cholestasis, lymphocytic inflammation, arterialization of central venules, hypocellular bridging fibrous septa connecting adjacent central areas. Patient was discharged with outpatient follow up after clinical improvement.

Hepato-biliary complications from Covid-19 remain an area of research. Some of the complications reported include cholangiopathy, acalculous cholecystitis and secondary sclerosing cholangitis. Cases of cholangiopathy are described as a late complication of Covid-19 with diagnosis upto 118 days post infection. Though the time of Covid-19 infection is unclear, intrahepatic cholestasis due to pancreatitis/medication and Covid-19 are all contributing factors in our patients' disease progression. Making an accurate diagnosis of Covid-19

cholangiopathy is prudent as it may progress to cirrhosis, especially if a patient has underlying liver pathology.