Sioux Falls Physician Diagnoses Autoimmune Hepatitis in Association with COVID-19

Hepatologist Govarthanan Rajendiran, MD, at Sanford Health is the first physician to diagnose a patient with autoimmune hepatitis in association with COVID-19 infection.1

Nearly a year into the pandemic, medical experts and researchers are still learning about the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its short- and long-term effects. Hepatic involvement had been widely reported. Typically, however, liver injury only occurs in the sickest of patients and is usually temporary. 

“Our patient’s case is rare and unique,” says Dr. Rajendiran. “Even though she recovered from COVID-19, her liver manifestation persisted for several weeks. We wanted to present her case study so that the medical community could be aware and see if it is something that may need to be looked into further.”

Autoimmune problems have also been documented in severely ill COVID patients. In one report, critically ill patients with COVID-19 displayed hallmarks of extrafollicular B-cell responses similar to those reported in autoimmune settings.2 Another author reported autoantibodies against multiple targets, including phospholipids and type-I interferons, that were linked to COVID-19.3

A new case report

Rajendiran's 38-year-old female patient, who had no risk factors for chronic liver disease, developed jaundice, right-sided abdominal pain, abnormal urinary discoloration, and markedly elevated liver enzymes a few weeks after testing positive for the COVID-19 infection.

She had taken acetaminophen for fever and body aches but not for at least a week before the onset of liver enzyme elevation. N-acetylcysteine treatment was administered at the local hospital without significant liver test improvement. She was discharged with recommended monitoring of symptoms at home.

A week later at her outpatient follow-up appointment, her transaminase levels were still elevated. She still had abdominal pain, poor appetite, dark urine, light-colored stools, and pruritus. The woman was transferred to the Sanford USD Medical Center in Sioux Falls where a liver biopsy confirmed a diagnosis of autoimmune hepatitis.

Three milligrams of the oral steroid budesonide three times a day resolved her symptoms within six weeks and at eight weeks, the patient's liver test was normal again.

“We don’t know if this will happen again but we did want to document that COVID-19 can be associated with autoimmune hepatitis presentation and let other physicians know that, in our experience, budesonide is safe to use in a COVID-19 setting,” says Dr. Rajendiran.

References:

1 Rajendiran G, Brice C, Erickson K, Oliver T, Manatsathit W. Autoimmune Hepatitis Associated with COVID-19 Infection – A Diagnostic and Therapeutic Dilemma. S D Med. 2020 Nov;73(11);528 -532.

2 Woodruff, MC, Ramonell, RP, Nguyen, DC et al. Extrafollicular B cell responses correlate with neutralizing antibodies and morbidity in COVID-19. Nat Immunol 21, 1506–1516 (2020). https://doi.org/10.1038/s41590-020-00814-z

3 Woodruff MC, Ramonell RP, Lee EH, Sanz I. Clinically identifiable autoreactivity is common in severe SARS-CoV-2 infection. medRxiv 2020.10.21.20216192. Under review.