S2935 Autoimmune Hepatitis After COVID-19 Vaccine: An Unusual Complication

Abstract

Introduction: Vaccination against SARS-Cov2 has represented a major milestone in our ability to ameliorate the COVID-19 pandemic. The vaccines are generally safe and effective, but some adverse events have been reported, including recent reports of autoimmune-like hepatitis. This case report presents a rare diagnosis of autoimmune hepatitis after administration of an mRNA COVID-19 vaccine. Case Description/Methods: An 18-year-old man with no medical history presented after receiving the Pfizer COVID-19 vaccine in April 2021, and second dose in May 20221. In June of 2021, about two weeks after the second dose, the patient was found with AST 120 u/L, ALT 181 u/L, Platelets 90. See Table 1 for further lab values. Per family, prior liver chemistries were normal. Initial serological workup was completed, including viral hepatitis (Hepatitis A, B, C, E), CMV IgG and IgM, EBV IgG and IgM, ceruloplasmin, alpha-1-antitrypsin, iron studies, all of which were unremarkable. Patient was also found to have ANA titer 1:640, positive anti-smooth-muscle antibody of 1:640, IgG level of 1,845, and positive antibody to soluble liver antigen of 2.321. Abdominal MRI was completed with findings of splenomegaly 20 cm, radiographic evidence of advanced hepatic fibrosis Patient underwent a liver biopsy with foci of interface and lobular hepatitis, areas of bridging necrosis, and scarring and focal nodularity concerning for transition to cirrhosis. Given these findings and it's timing close to administration of COVID-19 vaccine, the patient was diagnosed with autoimmune hepatitis associated with the vaccine. Patient was started on steroids in November 2021, and later, azathioprine, with improvement of liver enzymes. Discussion: Autoimmune hepatitis is a rare complication of COVID-19 vaccines, reported in few case reports in the literature. The pathophysiology remains unclear but is hypothesized to be related to molecular mimicry. The mRNA vaccines developed against COVID-19 leads to the production of the spike protein, and its antibodies. Antibodies to the spike protein have high affinity toward other human tissue proteins, which can lead to autoimmune tissue injury. In most reports, patients improved after treatment with steroids, though two have been reported to have passed away of liver failure. No liver transplants have yet been reported. Given the serious implications of this disease and the number of vaccines against COVID-19 given world-wide, further research is needed to better understand this entity and its pathophysiology. Table 1. - Lab Values 6/6/2021 11/15/2021 12/2/2021 1/12/2022 2/11/2022 4/18/2022 5/30/2022 AST U/L 120 323 31 35 48 37 50 ALT U/L 181 519 87 58 74 44 48 ALK P U/L 265 292 165 101 109 116 124 PLATELET COUNT 90 86 93 82 96 111 98