Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), or COVID-19, is primarily presenting in infected patients with general signs of pneumonia, i.e., fever, dyspnea, coughing and desaturation, with a large number of infected patients being asymptomatic. Nearly 5-10% of patients go on to develop the need for intensive care and intubation with mechanical ventilation.

Acute phase laboratory findings in admitted COVID-19 patients commonly include elevated C-reactive protein and ferritin, and elevated lactate dehydrogenase, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), pointing to liver damage. Recent evidence indicates that liver injury, by means of elevated aminotransferase levels, was more frequently seen in severe COVID-19 cases compared to patients with mild symptoms.

It is already known that several (respiratory) viruses can alter liver functions by means of (CD8 +) immune cell-mediated reactions. It is being hypothesized that liver impairment in COVID-19 patients could be drug-related, as is the case in patients suffering from certain viral infections who are susceptible to develop drug-induced liver injury (DILI), especially when associated with highly active anti-retroviral therapy.

Hydroxychloroquine is also being used in COVID-19 patients. The effect of the drug on hepatic tissue seems obscure. It is used to treat liver infection with protozoa (i.e. malaria); however, cases of fulminant hepatic failure have been reported.

While it is not clearly understood if a link exists between COVID-19 and liver steatosis, it can’t be ignored that a recent post-mortem histopathological analysis of a liver biopsy of a COVID-19 patient revealed microvesicular liver steatosis. Patients with COVID-19 have also been shown to have elevated serum levels of monocyte chemoattractant protein-1 (MCP-1), a chemokine known to exacerbate steatohepatitis.

SARS-CoV-2 infection could possibly have an impact on normal hepatic functions and the drugs used for the treatment of COVID-19 have already been shown to have hepatotoxic effects. Still, more mechanistic studies are needed to understand SARS-CoV-2 entry and replication in liver cells and the potential effects of medication on vital organs, including liver.

Source: Boeckmans J, Rodrigues RM, Demuyser T, et al. COVID-19 and drug-induced liver injury: a problem of plenty or a petty point? Arch Toxicol. 2020 Apr 8 : 1–3.