S3106 N-Acetyl Cysteine Use in the Treatment of Ischemic Hepatitis in the Setting of COVID-19 Infection

Abstract

Introduction: Acute liver injury occurs in 15-53% of COVID-19 patients. Most often, elevation in transaminases is mild, but severe liver injury has been described possibly secondary to hepatic ischemia. We present a case of ischemic hepatitis with concurrent COVID-19 infection, in which N-acetyl cysteine (NAC) administration led to clinical improvement and recovery. Case Description/Methods: A 58-year-old male with adult congenital heart disease (ACHD), on warfarin for atrial flutter and cardiac cirrhosis presented to the ER with generalized fatigue, chills, congestion, and cough. Patient tested positive for COVID-19. He was hemodynamically stable with an unremarkable exam. He was alert and oriented times three. He initially required 8 L of oxygen which continued to improve on a daily basis. His initial laboratory workup was notable for AST 1954 U/L, ALT 1905 U/L, INR 19.1, and total bilirubin 0.9 mg/dL. At baseline, patient’s liver enzymes were normal. He was admitted to the ICU due to the severity of his liver injury. Alcohol, acetaminophen, salicylate levels and urine drug screen were all within normal limits. Abdominal ultrasound revealed known liver cirrhosis and ascites. Acute hepatitis serologies including hepatitis E IgM, ANA, AMA, ASMA, anti-LKM, IGG subclasses, ceruloplasmin, alpha-1 antitrypsin, and celiac panel were done and unremarkable. In addition, HIV, VZV PCR, EBV PCR, HSV PCR and CMV PCR were also negative for acute infection. Patient was treated with a NAC protocol with decrease in elevated liver enzymes by half in the first 72 hours and >20-fold of the highest level upon discharge. Throughout his admission, his mental status remained normal. Discussion: Ischemic hepatitis (IH) results from insufficient blood flow volume and/or oxygen content to the hepatocytes. Acute hypoxic respiratory failure as a result of COVID-19 infection is one of the potential causes of this type of liver injury. Other possible causes of liver injury include direct viral cytopathic effect, cytokinesis and drug-induced liver injury. In the setting of COVID 19 infection, prompt diagnosis and recognition of IH is critical as studies describe mortality rates as high as 50%. We describe our clinical experience with NAC in the setting of COVID 19 with severe IH and propose that NAC is considered in the treatment of COVID-19 patients with ischemic hepatitis, however further research including prospective clinical trials is needed to better validate this.