Mithil Gowda Suresh, MD1, Curuchi Anand, MD1, Aakriti Soni, MD1, Anuroop Yekula, MD2, Safia Mohamed, MBBS3 1St. Vincent Hospital, Worcester, MA; 2Saint Vincent Hospital, Worcester, MA; 3Landmark Medical Center, Woonsocket, RI
Introduction: Coronavirus Disease 2019 (COVID-19) caused by SARS-COV-2 has led to a global crisis of unprecedented reach and proportion. In addition to the pulmonary consequences, the incidence of liver injury is increasingly being reported. Understanding the hepatotropism of SARS-COV-2 is of paramount importance as it can lead to a severe COVID-19 course. This case details a unique presentation of cholestatic hepatitis likely a sequela of a severe SARS-COV-2 infection in our patient.
Case Description/Methods: A 49-year-old lady with a history of seizure disorder, migraines, hypertension, and recent six-week ICU admission for COVID illness requiring mechanical ventilation (ECMO), presented to our gastroenterology clinic for a post-discharge follow-up. During admission, she consistently had an abnormal elevation of liver enzymes (Peak ALP 2000, AST, ALT 300, Bilirubin 2.5). MRCP was normal and a liver biopsy showed marked intralobular bile duct injury showing severe cytologic atypia, periductal edema, periductal and intraductal neutrophilic, and lymphocytic inflammation and marked ductular reaction, focal mild hepatocellular cholestasis, Kupffer cell hyperplasia. She had no prior history of chronic liver disease and LFT was normal at baseline. Post discharge LFT showed alkaline phosphatase of 1514 with total bilirubin 1.4. Infective (Hepatitis A, B, C panel), Inflammatory/Autoimmune (ANA, ASMA, AMA, P-ANC, Anti-SLA/LP, Anti ds-DNA, ALKM-1, and ALKM-3) workup was negative. Repeat imaging with USG and MRI was unremarkable. She received a course of prednisone after discharge with no improvement in LFT, it was tapered off. She is currently asymptomatic 6 months after acute illness but continues to have persistently elevated liver enzymes with a gradual downtrend with the latest being ALP 490, AST 86, ALT 95, and T. Bilirubin 0.8.
Discussion: We describe a unique case of post-COVID-19 cholestatic hepatitis with persistently elevated liver biochemistry with unclear etiology despite extensive workup. It could be a confluence of Secondary Cholangitis in Critically Ill Patients (SSC-CIP) and direct hepatic injury from COVID-19. Further data is needed to understand the patterns of liver injury due to COVID and the development of possible treatment for this newly described condition associated with the virus.
Disclosures:
Mithil Gowda Suresh indicated no relevant financial relationships.
Curuchi Anand indicated no relevant financial relationships.
Aakriti Soni indicated no relevant financial relationships.
Anuroop Yekula indicated no relevant financial relationships.
Safia Mohamed indicated no relevant financial relationships.
