S2658 Two for One: A Case of COVID-19 and Epstein-Barr Virus-Induced Acute Liver Injury

Abstract

INTRODUCTION: The majority of patients with COVID-19 present with respiratory symptoms, but little is known about the hepatic manifestations of the infection. Retrospective studies have shown that in patients with COVID-19 that developed abnormal liver tests, a majority were male, had high fevers ( > 102F) and higher levels of inflammatory markers, including ferritin. The degree of liver enzyme elevation was generally mild and transient. Currently there is no data to illustrate that patients with COVID-19 infection are at a greater risk of developing concomitant viral hepatitis infections. We present a case of a young patient with no other comorbidities, presenting with acute Ebstein-Barr viral hepatitis in the setting of COVID-19 infection. CASE DESCRIPTION/METHODS: An 18-year old male with no medical history was brought to the hospital after sustaining a nasal fracture after a fall due to alcohol intoxication. On admission, his COVID-19 screen was positive and he was febrile to 100.3F, oxygenating at 98% on room air, with mild symptoms of fatigue and malaise. On labs, he had elevated liver enzymes with aspartate transaminase (AST) of 326 U/L, alanine transaminase (ALT) of 401 U/L with normal bilirubin and alkaline phosphatase levels. Ferritin was elevated to 1342 ng/mL. A doppler ultrasound showed hepatic steatosis with patent hepatic vessels. A CT chest with contrast showed mild bronchial wall thickening suggestive of infectious or inflammatory airway process. He was started on Augmentin for presumed COVID-19 pneumonia, which was discontinued after 2 doses due to up trending transaminases seen in Table 1, and later switched to Levofloxacin. Due to the degree of elevation, he underwent an extensive workup for other causes of acute liver injury illustrated in Table 2. Ultimately, he was found to have an acute Ebstein-Barr (EBV) viral hepatitis infection. On hospital day 6, liver enzymes and ferritin began to downtrend and a liver biopsy was deferred. He remained asymptomatic was discharged with standard COVID-19 precautions. DISCUSSION: Case studies have shown that abnormal liver function tests during the course of COVID-19 are common, however clinically significant liver injury is rare. Our patient developed acute liver injury with liver enzymes that were much higher than typically seen solely with COVID-19 infection. This case illustrates the importance of maintaining a high clinical index of suspicion to evaluate for other concomitant causes of acute liver injury even in COVID-19 positive patients.Table 1.: Trend of AST, ALT and ferritinTable 2.: Lab tests and results for alternative causes of acute liver injury