Three young adults developed "prolonged and severe" liver disease during recovery from critical cases of COVID-19, a case series reveals. "Liver test abnormalities occur in 30%-70% of patients hospitalized with COVID-19, but have been described as reversible and not clinically significant, apart from perhaps helping prognosticate more severe disease," Dr. Nitzan Roth of Hofstra/Northwell in Manhasset, New York told Reuters Health by email. "In other words, the liver was previously felt to be an 'innocent bystander.' with no long-lasting sequela in patients without prior liver disease." "We describe a progressive, chronic post-COVID cholangiopathy that appears to be a variant of secondary sclerosing cholangitis with unique, previously undescribed, histologic features that suggest possible direct hepatic injury from COVID-19 itself," he said. "This post-COVID cholangiopathy occurs during recovery from critical COVID-19 and, in some patients, is chronic with progression to cirrhosis and possible liver failure." "Since we first described this entity, we have seen multiple additional cases of varying severity," he noted. "Clinicians should recognize the existence of post-COVID cholangiopathy and, when it is suspected, should counsel the patient appropriately and consider recommending liver biopsy to evaluate for the specific histologic features and signs of chronicity." Dr. Roth and colleagues reported on a 38-year-old non-Hispanic/White male; a 25-year-old Hispanic/Multiracial male; and a 40-year-old Hispanic/Multiracial female with prolonged and severe cholestasis during recovery from critical COVID-19. None had preexisting chronic liver disease, although the female patient had diabetes. The case series was published in the American Journal of Gastroenterology. All three patients had a prolonged hospitalization because of acute hypoxemic respiratory failure requiring mechanical ventilation and other COVID-19-related complications, including acute kidney injury, hydropneumothorax; embolic stroke (one male), tension pneumothorax, recurrent hemothorax, subcapsular hematoma after liver biopsy (second male), and cardiac arrest (female). As of September 26, 2020 (range of followup, 167-189 days), two patients were discharged home and one remained hospitalized. Liver chemistries were normal or mildly elevated on admission. All patients had severe, but brief, aminotransferase elevations early in their hospitalizations, believed to have been secondary to ischemic hepatitis. All subsequently developed cholestasis with associated jaundice that persisted long after cardiopulmonary and renal recovery. Laboratory studies for non-SARS-CoV-2 acute or chronic viral infections and autoimmune serologies were negative. Liver imaging showed no evidence of cirrhosis Magnetic resonance cholangiography was abnormal in two patients, prompting endoscopic retrograde cholangiography with removal of biliary sludge and, for one patient, extraction of small extrahepatic duct stones. Percutaneous liver biopsies revealed at least moderate portal and periportal fibrosis. One biopsy exhibited bridging portal-to-portal and portal-to-central fibrosis with focal fibrotic obliteration of terminal hepatic veins. The authors note, "We believe the post-COVID-19 cholangiopathy described herein represents a confluence of SSC-CIP and direct hepatic injury from COVID-19." Dr. Niket Sonpal, associate program director of IM residency at Brookdale University Hospital and Medical Center and course director at Touro College of Osteopathic Medicine, both in New York City, commented in an email to Reuters Health, "These three cases represent an interesting phenomenon and illustrate that the depth of understanding of COVID19 is still superficial. I have not encountered similar cases, but we have seen patients with cholecystitis and increased liver function tests during active infection." "The patients in this article were very sick and I feel that the liver injury and cholestasis could be due partially to COVID-19, but also to the overall severity of illness," he said. "A great deal more research is needed to understand the underlying microbiological mechanisms as to why they developed prolonged cholestasis. Was it COVID19 directly or was it the acute hypoxemic respiratory failure injuring the liver? Which came first?" —Marilynn Larkin Source
