S2688 COVID-19-Induced Acute Hepatitis Treated Successfully With N-Acetylcysteine: Case Report

Abstract

INTRODUCTION: Mild liver impairment is widely reported in patients with COVID19. However, Acute hepatitis (AH) was reported in only one case found in a 99-case series published in China.N- acetylcysteine (NAC) is a known medication used in acetaminophen-induced hepatitis, works as a hepatoprotective agent via multiple mechanisms, including restoring hepatic glutathione as well as an antioxidant. It seems that its therapeutic use could be extended to manage cases of AH induced by other medical conditions like COVID 19 as in our case. CASE DESCRIPTION/METHODS: 64 years old male presented with progressive dyspnea, fever, and myalgia. He was diagnosed with COVID19 at a different facility two days prior to the current presentation and was sent home to self-quarantine. On presentation, the patient was mildly hypoxia that responded to nasal oxygen, but never hypotensive. Laboratory results were significant for elevated aspartate transaminase (AST) and alanine transaminase (ALT) at 1,264, 767 Units/L respectively. Alkaline phosphates showed a 1.5-fold increase from his baseline. Total bilirubin, Albumin, prothrombin time, partial thromboplastin time, international normalized ratio (INR) were all normal throughout hospitalization. Viral hepatitis panel and autoimmune hepatitis panel (including anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, and immunoglobulin G level were also negative. Serum salicylate and acetaminophen levels, urine toxicology screening test, and respiratory viral panel (novel Coronavirus not included) were all negative. Serum ferritin was elevated at 20,325 ng/mL, while serum iron was 40 mcg/dL and total iron-binding capacity was 282 mcg/dL. Upon admission, the patient was given a loading dose of NAC followed by maintenance doses. Two days later, AST and ALT started to trend down. Two days later, alkaline phosphatase followed suit. The patient was also placed on the COVID19 treatment regimen used in our facility, including Azithromycin, Hydroxychloroquine, and Zinc sulfate. Systemic corticosteroids were initiated on day 6 due to worsening hypoxia. Eventually, the patient’s inflammatory markers normalized on day 9. Hypoxia improved and he was successfully discharged home. DISCUSSION: We reported a rare case of COVID19 induced AH along with our observation of possible benefit from using NAC in treating this condition. NAC is known for its safety profile. Hence, we believe that more studies need to investigate the role of NAC in treating cases of AH.Figure 1.: Liver enzymes trending over time. ALT( alanine transaminase), AST Aspartate transferase, ALk Pho (alkaline phosphatase).Figure 2.: Patient vital signs during admission.