Secondary Sclerosing Cholangitis in a Critically Ill Patient with Severe SARS-CoV-2 Infection: A Possibly Emergent Entity during the Current Global Pandemic

Abstract

A 46-year-old woman without previous history of hepatobiliary disease was admitted to the intensive care unit due to SARS-CoV-2 infection. Admission blood tests revealed impending hyperinflammation in the context of systemic inflammatory response syndrome. She required 12 days of mechanical ventilation and vasopressor support. After admission, liver function tests became deranged in a cholestatic pattern and continued to worsen despite overall clinical improvement. Magnetic resonance cholangiopancreatography revealed liver abscesses, intrahepatic bile duct dilation with multiple strictures and some linear repletion defects at the bifurcation of the common hepatic duct. During endoscopic retrograde cholangiopancreatography, biliary casts were retrieved confirming the diagnosis of secondary sclerosing cholangitis in the critically ill patient triggered by a severe SARS-CoV-2 infection. Other causes of cholestasis and secondary sclerosing cholangitis were properly excluded. We present an illustrative case and discuss the current literature, focusing on SARS-CoV-2 infection contribution to the development of this potentially underdiagnosed and severe condition.

Keywords: Biliary casts; COVID-19; Cholestasis; Critical care; SARS-CoV-2; Secondary sclerosing cholangitis.

Fig. 1

Kinetics of liver function tests since hospital admission. AST, aspartate aminotransferase; ALT alanine aminotransferase; ALP, alkaline phosphatase; GGT, gamma-glutamyl transpeptidase.

Fig. 2

Magnetic resonance imaging with cholangiopancreatography. Left − T1 portal venous phase with subcapsular clustered hypointense lesions with peripheral enhancement (*). These lesions had a hyperintense signal in the T2 sequence, suspected of microabscesses. Middle − cholangiographic T2 sequence, showing linear repletion defects at the bifurcation of the common hepatic duct (arrows). Right − cholangiographic 3D sequence showing dilation of intrahepatic bile ducts, with parietal irregularity, strictures, and post-stenotic dilations, suggesting sclerosing cholangitis.

Fig. 3

Endoscopic retrograde cholangiopancreatography. Left − ERCP X-ray images after injection of contrast media, showing an ill-defined filling defect at the common hepatic duct bifurcation and irregular filling of intrahepatic bile ducts. Right − biliary casts that were retrieved from the common hepatic duct and left and right hepatic ducts, using an extraction balloon and a Dormia basket.