S2694 Severe Acute Liver Failure in a Patient With SARS-CoV-2 Infection

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Introduction: Hospitalized patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, are regularly found to have elevated LFTs. Up to 46% had elevated AST and 35% had elevated ALT. Occasional elevations in GGT, ALP, and total bilirubin are also seen. These elevations were usually below 5 times the upper limit of normal (ULN). Less than 10% of patients had severe liver injury (ALT > 5 times ULN). Hepatic injury in COVID-19 can be attributed to numerous causes including direct injury, drug toxicity and inflammatory storm. Direct injury is thought to occur when SARS-CoV-2 binds directly to ACE-2 which are abundantly expressed in biliary and liver epithelial cells. We present the case of an 88-year-old COVID-19 patient with severe liver failure managed conservatively. Case Description/Methods: 88-year-old male with history of CHF, atrial fibrillation on Apixaban, DM-2, HTN and recent diagnosis of COVID-19 presented with shortness of breath. Vitally, he was normotensive but hypoxic. Initial labs are shown in Table 1. He denied an established history of liver disease, alcohol use or hepatotoxic drug use. Chest CTA had findings concerning for COVID-19 pneumonia and acute pulmonary embolism. He was not started on Remdesivir due to elevated LFTs. His acute hepatitis panel and acetaminophen level were negative. The patient’s LFTs continued to worsen over his hospital course (Image 1). Transfer to a tertiary liver center was not considered due to his tenuous condition, age, and comorbidities. On day five the patient’s AST and ALT started trending down. However, total bilirubin continued to rise, and ALP stayed relatively stable. His respiratory status continued to worsen, and he was eventually transitioned to comfort care. Discussion: In the absence of an established history of liver disease, alcohol abuse, or hepatotoxic drug use, we believe that our patient’s acute liver failure might have been a direct complication of COVID-19 infection. Treatment with 1-2 drugs from the following categories: hepatoprotective, anti-inflammatory, and jaundice-reducing agents including polyene phosphatidyl choline, glycyrrhizic acid, bicyclol, and vitamin E has been proposed to reduce the burden of liver injury. With the increasing number of cases of liver injury with COVID-19, it is pivotal to identify its pathogenesis, acute interventions, and potential long-term complication to treat this life-threatening condition promptly and effectively.Table 1.: demonstrating our patient’s initial labs.Figure 1.: Image 1 demonstrating lab trend of our patient over his hospital stay.