Asymptomatic COVID-19 presenting with features of mixed pattern acute liver injury in a young healthy female, a case report

Abstract

COVID-19 associated severe acute liver injury in a young healthy patient has not been reported much in the literature. And currently, there are no standard management guidelines. We want to report a case of acute liver injury of mixed pattern in a young healthy female with asymptomatic COVID-19 infection. She presented with abdominal pain, nausea, vomiting and yellowish discoloration of her skin. Further laboratory investigations revealed mixed pattern liver injury with highly raised liver enzymes. She was managed with N-acetyl cysteine protocol and monitoring of her liver enzymes. Other causes of acute liver injury were ruled out. She remained stable during her hospital stay and follow up. Our aim is to highlight the significance of acute liver injury in COVID 19 patients that may lead to fatal outcomes if not managed and monitored accordingly.

Keywords: Abnormal liver enzymes; Acute hepatitis; COVID-19; Liver Injury; N-acetyl cysteine (NAC).

Fig. 1

Possible mechanisms of liver injury in COVID 19.

Fig. 2

Proposed algorithm based on literature review: *Chronic liver diseases and other underlying liver diseases: HCV, HBV, alcoholic liver, hemochromatosis, Non-alcoholic fatty liver disease, Wilson’s disease, alpha-1 anti-trypsin deficiency, primary biliary cholangitis, primary sclerosing cholangitis, auto-immune hepatitis etc. **Other cause of raised liver enzymes other than liver injury: myositis (especially glutamic oxalacetic transaminase > ALT), cardiac injury, ischemia, and cytokine release syndrome . ***Likely causes of drug induced liver damage in COVID 19 patient: anti-viral drugs like Remdesevir, Lopinavir/Ritonavir, corticosteroids, Oseltamivir, Tocilizumab, tofacitinib, Acetaminophen, SARS-Cov-2 Vaccination, antibiotics like azithromycin, anti-malarial like hydroxychloroquine .