COVID-19 Infection Presenting as an Isolated Severe Acute Liver Failure

Abstract

The clinical features of severe acute respiratory syndrome-coronavirus disease 2019 (SARS-COVID-19) infection range from mild upper respiratory symptoms to severe acute respiratory failure. Among other less common features are diarrhea, nausea, vomiting, elevated liver enzymes, and acute kidney injury. We present a case of a 49-year-old female with no preexisting liver disease who presented with weakness and dizziness for one week. Initial investigations revealed acute liver failure (ALF) and positive COVID-19 on polymerase chain reaction (PCR) testing. The patient did not have any upper or lower respiratory symptoms, and extensive workup to look for other etiologies of acute liver failure was unremarkable. She eventually deteriorated to decompensated liver failure and was transitioned to comfort measures only. Liver injury is a well-documented phenomenon associated with COVID-19 infection. Some of the common pathophysiological mechanisms include direct liver injury, immune-mediated liver damage due to the severe inflammatory response, ischemic injury, endothelial disruption, and coagulopathy. Our case uniquely highlights that SARS-COVID-19 infection may have the potential to solely affect hepatocytes without the classic severe acute respiratory distress syndrome. This case demonstrates that a diagnosis of COVID-19 may be considered if no other etiology of ALF is identified.

COVID-19 and liver injury: An ongoing challenge

“…Furthermore, liver injury in COVID-19 has been noted to be transient, while hepatic biochemical tests return to normal within 2-3 wk[ 6 ]. Severe liver injury, with aminotransferases > 20 times ULN, has been observed in 0.1% of COVID-19 patients on admission and in 2% during hospitalization, while acute liver failure, induced by COVID-19, has been reported in extremely rare cases[ 27 , 28 ]. Febrile hepatitis, acute cholecystitis and hepatic artery thrombosis are, also, rare clinical presentations of COVID-19[ 29 - 31 ].…”

COVID-19-Triggered Acute Liver Failure and Rhabdomyolysis: A Case Report and Review of the Literature

“…Several reports have highlighted the occurrence of liver enzyme abnormalities, acute hepatitis, and an ALF associated with SARS-CoV-2 infection [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. It has been documented that approximately 76.3% to 82.5% of COVID-19 cases display abnormal liver test results [ 35 , 37 ].…”

“…Moreover, Sobotka et al indicated that severe acute liver injury (ALI) was infrequent, occurring in 0.1% of patients upon admission and 2% during hospitalization, with no ALF observed among a cohort of 1555 patients [ 30 ]. The available literature on ALF in the context of COVID-19 remains limited, with only a handful of reports documenting such cases [ 39 , 40 , 41 , 42 , 43 ]. The reports on ALF cases are provided in Table 2 , with the main findings summarized.…”

“…Among the reports, including a systematic review that provided laboratory data for reference, none documented cases that were complicated by both ALF and rhabdomyolysis in association with COVID-19 [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 51 ]. However, the information presented in these reports shows resemblances in the underlying factors between ALF and rhabdomyolysis.…”

Metabolic Associated Fatty Liver Disease (MAFLD) and COVID-19 Infection: An Independent Predictor of Poor Disease Outcome?

“…Patients with preexisting liver disease (LD) are more susceptible to disease deterioration during an infection, with COVID-19 being one of the most challenging ones [24]. However, this phenomenon was also noted in patients without previous liver dysfunction [25]. It has been postulated that an uncontrolled immune response with a high release of cytokines causing hyperinflammation and consequently multi-organ damage may be one of the possible causators [23].…”