COVID-19 caused by severe acute respiratory syndrome coronavirus 2 infection, has emerged as a global pandemic. Although, initially considered a respiratory disease, it can causes severe complications including gastrointestinal, neurological, thromboembolic and cardiovascular leading to multiple organ dysfunction and death. The authors of the present stu...
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COVID-19 caused by severe acute respiratory syndrome coronavirus 2 infection, has emerged as a global pandemic. Although, initially considered a respiratory disease, it can causes severe complications including gastrointestinal, neurological, thromboembolic and cardiovascular leading to multiple organ dysfunction and death. The authors of the present study reviewed a case of 57-year-old man with a medical history of hypertension, prediabetes and beta thalassemia minor. The patient developed shortness of breath, and cough and was diagnosed with COVID-19 by RT-PCR. He was quarantined at home for 2 weeks and his respiratory symptoms resolved. However, he further developed fatigue and multiple joint pain involving the hand, wrist, knee and shoulder which progressively aggravated. He had no history of nausea, vomiting, abdominal pain, itching, rash, bleeding from the nose or mouth, or blood in stools, and alcohol or drug abuse, blood transfusions or iron supplementation.
His blood workup showed that hepatitis A IgM antibodies (HA Ab-IgM), hepatitis B surface antigen (HBsAg), hepatitis B IgM core antibody (HBcAb-IgM), and hepatitis C antibodies (HC Ab) was negative, HIV was negative. Other laboratory investigations showed hyperferritinemia, elevated liver enzymes (AST/ALT/GGT), hypergammaglobulinemia, anti-smooth muscle antibody, anti-mitochondrial antibody and anti-double-stranded DNA antibodies). Ultrasound of the abdomen revealed a normal sized liver with mild heterogeneous parenchyma and a slightly lobulated contour. There was a 12 mm cyst in the right hepatic lobe posteriorly. No evidence of intra-hepatic biliary ductal dilatation was seen and the common bile duct diameter was 6 mm. There was no evidence of gallstones. Endoscopy showed gastritis and colonoscopy showed internal haemorrhoids. The patient was taking fenofibrate which has been associated with autoimmune hepatitis (AIH).
The patient was diagnosed with autoimmune hepatitis–primary biliary cholangitis (PBC) overlap syndrome stimulated by COVID-19. He was then started on ursodeoxycholic acid and continued to be followed up.
AIH–PBC overlap syndrome is diagnosed when two or three criteria for PBC and AIH are met. AIH is diagnosed when two out of the following three criteria are present; (a) alanine aminotransferase (ALT) lev ls >5×ULN, (b) serum immunoglobulin G (IgG) levels >2×ULN or a positive test for anti-smooth muscle antibodies (ASMA), and (c) liver biopsy specimen showing moderate or severe periportal or periseptal lymphocytic piecemeal necrosis. PBC is diagnosed when two out of the following three criteria are present: (a) alkaline phosphatase (AP) levels >2×ULN or γ-glutamyl transpeptidase (GGT) levels >5×ULN, (b) a positive test for antimitochondrial antibodies (AMA), and (c) liver biopsy specimen showing florid bile duct lesions. This patient met 2/3 criteria for each of AIH and PBC, though a liver biopsy was not conducted. Therefore, healthcare professionals should be cautious of uncommon manifestation of COVID-19 so that early diagnostic and therapeutic strategies can be implemented.
Source: Singh B, Kaur P, Maroules M. Autoimmune Hepatitis-Primary Biliary Cholangitis Overlap Syndrome Triggered by COVID-19. Eur J Case Rep Intern Med. 2021 Feb 4;8(3):002264.
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