S2415 COVID-19 Infection Presenting as Acute Hepatitis in a 22-Week Pregnant Woman

Abstract

INTRODUCTION: Coronavirus disease (COVID-19) is caused by a newly identified coronavirus, SARS-CoV-2, has caused a worldwide pandemic of illness. There are several reports of abnormal liver tests with COVID-19 but there is limited data about the course and patient outcomes of COVID-19 in pregnant women. We report a case of acute non-icteric hepatitis in a pregnant patient presenting with COVID-19 infection. CASE DESCRIPTION/METHODS: A 27 year-old, 22 weeks pregnant, female presented with a chief complaint of fever, cough and decreased oral intake. She has a PMH of sickle cell trait. She denied recent intake of any new medications including acetaminophen, over the counter products or antibiotics. Her outpatient medications included prenatal vitamins. Outpatient liver chemistries at her last pre-natal appointment were normal. On admission, her vital signs were stable. There were no cutaneous manifestations, her lung examination was normal and there was no jaundice, right upper quadrant tenderness, hepatomegaly or splenomegaly. Fetal exam was normal. Laboratory values were as follows: platelets 237,000 mL, serum bilirubin 0.7 mg/dL (Nl < 25), AST 674 IU/L (Nl < 50), ALT 624 IU/L (Nl < 50), alkaline phosphatase 330 IU/L (Nl < 125), serum albumin 3.7 g/dL (N > 3.5), INR 1.17, lactate dehydrogenase 396 U/l (N < 242). A COVID-19 PCR test was positive. O2 sat 98-99% on room air. Abdominal sonogram revealed a normal liver. Serological tests for acute hepatitis A, B and C were negative. Infectious workup was also negative. She was monitored in the hospital for 3 days and discharged to home. At her one month outpatient follow up, serum bilirubin 0.3 mg/dL, AST 34 IU/L, ALT 52 IU/L, alkaline phosphatase 148 IU/L, serum albumin 3.9 g/dL, INR 1.02. Her pregnancy has since been uncomplicated and she has been closely followed by her obstetrician. DISCUSSION: This 22-week pregnant woman presented with acute hepatitis secondary to COVID-19 infection which improved without intervention. While abnormal liver tests are frequently seen in COVID-19 infection, acute hepatitis is uncommon. Clinical manifestations of COVID-19 can overlap with those of normal pregnancy such as nausea, vomiting, fatigue, shortness of breath while abnormal liver chemistries in pregnancy are always abnormal and necessitate further evaluation. In addition to other causes of acute hepatitis in pregnancy, this case illustrates that COVID-19 infection should be considered in the differential diagnosis in pregnant women presenting with acute hepatitis.Figure 1.: Liver tests during hospital course.