S2681 A COVID-19 Infection Presenting Solely as Acute Hepatitis

Abstract

Introduction: Severe acute respiratory syndrome coronavirus 2 infection, referred to as Covid-19, has become a global pandemic affecting over 50 million patients according to the World Health Organization. Patients suffering from Covid-19 classically present with respiratory complaints, but gastrointestinal symptoms have also been noted. Acute liver injury (ALI) has been associated with Covid-19 infections but the transaminitis is typically mild. Severe injury correlates with severe disease and poor outcomes. We document a case of acute hepatitis due to Covid-19 in a patient presenting solely with abdominal pain. Case Description/Methods: A 55 year old female presented to the hospital for a two day history of upper abdominal pain and associated emesis. The patient noted eating at a restaurant days prior to symptom onset but denied other new habits or medications. Labs demonstrated an AST of 1,099IU/L (0-31 IU/L), ALT 1,003IU/L (0-31 IU/L), total bilirubin 0.7mg/dL (0-1mg/dL), and alkaline phosphatase 93IU/L (39-117IU/L). Acetaminophen level was negative. A doppler ultrasound revealed hepatomegaly, patent vasculature and a normal gallbladder and common bile duct. A viral hepatitis panel was negative. EBV IgM was < 36 U/mL (< 36 U/mL) and EBV IgG was > 750 U/mL (< 18 U/mL). Autoimmune markers were negative. On the second day, her SARS-CoV-2 test resulted positive. Over the span of two days her AST and ALT had decreased to 476 IU/L and 714 IU/L respectively. Her abdominal pain resolved, and the patient was discharged home. Discussion: ALI is frequently seen in Covid-19 with AST/ALT elevations in up to 60% of patients. Elevations are usually 1-2 times the upper limit of normal. Studies have demonstrated that severe injury, a mean transaminase over 10 times the upper limit of normal, is associated with worse outcomes. It is thought that the virus’ predilection for ACE2 receptor within hepatic cholangiocytes allows for viral entry and direct damage. However, injury may also result from sepsis and therapeutics. It's uncommon that a patient without respiratory symptoms and poor clinical condition should present with a transaminitis as significant as ours. Upon literature review, there was only one other case documenting significant liver injury in an otherwise asymptomatic patient. Our patient had no medications that could have contributed to her condition and an unremarkable workup. It was thought her transaminitis was secondary to Covid-19, but a liver biopsy would have been useful for a definitive diagnosis.Figure 1.: Chest radiograph without evidence of parenchymal lung disease.