Coronavirus disease (COVID-19), a novel enveloped RNA beta-coronavirus was first emerged in Wuhan, China, in December 2019 and rapidly spread worldwide pandemic affecting more than 25 million people. 

The most common symptoms included respiratory symptoms such as shortness of breath, dyspnea, fever and cough, along with radiological findings similar to interstitial pneumonia. Acute liver injury at admission is a frequent finding in patients affected by COVID-19 pneumonia. It has been observed that increase in aminotransferases is generally mild; however, it has been found to be correlated to disease severity. Majority studies show that SARS-CoV-2 infection in the liver leads to hepatic impairment in patients with COVID-19 pneumonia.

The investigators of the present study report the case of a young woman diagnosed with COVID-19 infection without respiratory symptoms> she presented at the admission with remarkable increase of liver function tests similar to acute hepatitis.

A 30-years old woman was admitted at the emergency department for mild fever, anosmia and dysgeusia from 10 days. She did not have the history of cough, sore throat, shortness of breath, diarrhea, nausea, vomiting, or abdominal pain. She had a positive history of contact with COVID-19 patients in previous three days. There was no history of any chronic disease and she was not taking any drug at the time of admission.

A nasopharyngeal swab was conducted and RT-PCR resulted positive for COVID-19 infection. Chest X-ray did not report findings compatible with interstitial pneumonia; arterial oxygen saturation was 99% on room air. On presentation, her temperature was 36 °C. There were no cutaneous manifestations, her lung examination was normal, and there was no jaundice, right upper quadrant tenderness, hepatomegaly, or splenomegaly. Laboratory results showed AST 1531 IU/L (normal value < 35), ALT 893 IU/L (normal < 36), serum bilirubin 1.02 mg/dL (normal < 1.2), alkaline phosphatase 106 IU/L (normal 33–98), INR 1, gammaglutamiltransferase 1276 IU/L (normal < 40), white blood cells 4070 cells/mm³ (normal 4000–10,000), platelets 152,000 cells/mm³ (normal 150,000–450,000). The abdominal ultrasound did not show remarkable abnormalities of liver, gallbladder, kidneys, spleen, pancreas and abdominal vessels. Serological testing for hepatitis A, B, C, E, Cytomegalovirus, Epstein-Barr and respiratory viral panel were negative. Blood cultures for bacteria and fungi, and the screening for autoimmune diseases were also negative. 

She was managed with infusion of saline solution 0.9% (1500 cc/daily) with progressive decline in liver abnormalities. Day 3 laboratory results reported AST 111 IU/L, ALT 89 IU/L, alkaline phosphatase 97 IU/L and gammaglutamiltransferase 246 IU/L. She did not have any respiratory symptom during follow-up and the patient was discharged after 5 days of hospitalization, in good clinical condition.

This is the first reported case of COVID-19 infection presenting as acute hepatitis without presence of respiratory symptoms. She had very mild symptoms associated with COVID-19 infection. Other probable causes of liver abnormalities were excluded, suggestive of the fact that acute hepatitis was developed due to COVID-19. 

Therefore, patients with known risk factors for COVID-19 infection presenting with acute hepatitis should be promptly isolated and investigated. The patients studied in this report showed resolution of abnormalities in liver function tests in absence of specific therapy.

Source: Bongiovanni M, Zago T. Acute hepatitis caused by asymptomatic COVID-19 infection. J Infect. 2021;82(1):e25-e26.