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

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.

Progress in the Clinical Features and Pathogenesis of Abnormal Liver Enzymes in Coronavirus Disease 2019

With the rapid development of research on coronavirus disease 2019 (COVID-19), more and more attention has been drawn to its damage to extrapulmonary organs. There are increasing lines of evidence showing that liver injury is closely related to the severity of COVID-19, which may have an adverse impact on the progression and prognosis of the patients. What is more, severe acute respiratory syndrome coronavirus-2 infection, cytokine storm, ischemia/hypoxia reperfusion injury, aggravation of the primary liver disease and drug-induced liver injury may all contribute to the hepatic damage in COVID-19 patients; although, the drug-induced liver injury, especially idiosyncratic drug-induced liver injury, requires further causality confirmation by the updated Roussel Uclaf Causality Assessment Method published in 2016. Up to now, there is no specific regimen for COVID-19, and COVID-19-related liver injury is mainly controlled by symptomatic and supportive treatment. Here, we review the clinical features of abnormal liver enzymes in COVID-19 and pathogenesis of COVID-19-related liver injury based on the current evidence, which may provide help for clinicians and researchers in exploring the pathogenesis and developing treatment strategies.

Unusual glycogenic hepatopathy causing abnormal liver enzymes in a morbidly obese adolescent with well-controlled type 2 diabetes: resolved after A1c was normalized by metformin

We report, for the first time, a case of an accumulation of glycogen in the liver causing elevation of liver enzymes in a 15-year-old morbidly obese adolescent male with well-controlled type 2 diabetes. Notably, the patient did not have poorly controlled type 1 diabetes and did not require insulin. After normalization of the A1c with metformin, elevated liver enzymes returned to normal.

Endoscopic ultrasound-guided liver biopsy in pediatric patients

Endoscopic ultrasound (EUS) is routinely used for diagnostic and therapeutic purposes in adults, and there is emerging literature on its feasibility and safety in children. A recent novel application is EUS-guided liver biopsy (EUS-LB), which has shown to be technically simple, safe, and provides adequate diagnostic yield in adults for evaluation of liver disease; but the use of EUS-LB has never been evaluated in the pediatric population. We report the first case series of EUS-LB in the pediatric population, performed on 3 children, 1 girl and 2 boys-ages 9, 14 and 17 respectively, using a 19-gauge EUS-fine needle aspiration needle. All three cases were performed for the evaluation of unexplained elevated liver enzymes, with above-average diagnostic yield and without any immediate or delayed complications in all children. The use of EUS-LB was pivotal in the management of all the cases. Our case series illustrates the diagnostic utility and safety of EUS-LB in pediatric patients.

Recurrent gastrointestinal bleeding and hepatic infarction after liver biopsy

Hepatic artery pseudoaneurysms (HAP) are rare events, particularly after liver biopsy, but can be associated with serious complications. Therefore a high suspicion is necessary for timely diagnosis and appropriate treatment. We report on a case of HAP that potentially formed after a liver biopsy in a patient with sarcoidosis. The HAP in our case was virtually undetectable initially by angiography but resulted in several complications including recurrent gastrointestinal bleeding, hemorrhagic cholecystitis and finally hepatic infarction with abscess formation until it became detectable at a size of 5-mm. The patient remains asymptomatic over a year after endovascular embolization of the HAP. In this report, we demonstrate that a small HAP can avoid detection by angiography at an early stage while being symptomatic for a prolonged course. A high clinical suspicion with a close clinical/radiological follow-up is needed in symptomatic patients with history of liver biopsy despite initial negative work up. Once diagnosed, HAP can be safely and effectively treated by endovascular embolization.