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APRIL 10, 2020 -- A woman presented to the emergency department with high liver enzyme levels and dark urine. She developed fever on day 2 of care, and then tested positive for the new coronavirus, researchers at Northwell Health, in Hempstead, New York, report.
The authors say the case, published online in the American Journal of Gastroenterology, is the first documented instance of a patient with COVID-19 presenting with acute hepatitis as the primary symptom before developing respiratory symptoms.
Prior data show that the most common early indications of COVID-19 are respiratory symptoms with fever, shortness of breath, sore throat, and cough, and with imaging results consistent with pneumonia. However, liver enzyme abnormalities are not uncommon in the disease course.
"In patients who are now presenting with acute hepatitis, people need to think of COVID," senior author David Bernstein, MD, chief of the Division of Hepatology at Northwell Health, told Medscape Medical News.
In addition to Bernstein, Praneet Wander, MD, also in Northwell's hepatology division, and Marcia Epstein, MD, with Northwell's Department of Infectious Disease, authored the case report.
Bernstein said Northwell currently has the largest number of COVID-19 cases in the nation and that many patients are presenting with abnormal liver test results and COVID-19 symptoms.
He said that anecdotally, colleagues elsewhere in the United States are also reporting the connection.
"It seems to be that the liver enzyme elevations are part and parcel of this disease," he said.
According to the case report, the 59-year-old woman, who lives alone, came to the emergency department with a chief complaint of dark urine. She was given a face mask and was isolated, per protocol.
"She denied cough, sore throat, shortness of breath, diarrhea, nausea, vomiting or abdominal pain," the authors
She had well-controlled HIV, and recent outpatient liver test results were normal. Eighteen hours after she came to the ED, she was admitted, owing to concern regarding rising liver enzyme levels in conjunction with her being HIV positive.
On presentation, her temperature was 98.9° F. There were no skin indications, lungs were normal, and "there was no jaundice, right upper quadrant tenderness, hepatomegaly or splenomegaly."
Liver enzyme levels were as follows: aspartate aminotransferase (AST), 1230 (IU/L); alanine aminotransferase (ALT), 697 IU/L (normal for both is <50 IU/L); alkaline phosphatase, 141 IU/L (normal, <125 IU/L).The patient tested negative for hepatitis A, B, C, E, cytomegalovirus, and Epstein-Barr virus. A respiratory viral panel and autoimmune markers were normal.
Fever Appeared on Day 2
She was admitted, and 18 hours after she came to the ED, she developed a fever of 102.2° F. A chest x-ray showed interstitial opacities in both lungs.
Nasopharyngeal samples were taken, and polymerase chain reaction test results were positive for the novel coronavirus. The patient was placed on 3 L of oxygen.
On post admission day 4, a 5-day course of hydroxychloroquine (200 mg twice a day) was initiated.
The patient was discharged to home on hospital day 8. The serum bilirubin level was 0.6 mg/dL; AST, 114 IU/L; ALT, 227 IU/L; and alkaline phosphatase, 259 IU/L.
According to Bernstein, it's hard to tell in what order COVID-19 symptoms occur because people are staying home with other complaints. They may only present to the emergency department after they develop more typical COVID-19 symptoms, such as shortness of breath.
In this case, the patient noticed a darkening of her urine, "but if she had come the next day, she would have had fever. I think we just happened to catch it early," Bernstein said.
He added that he saw no connection between the underlying HIV and her liver abnormalities or COVID-19 diagnosis.
Bernstein notes that most COVID-19 patients are not admitted, and he said he worries that a COVID-19 test might not be on the radar of providers in the outpatient setting when a patient presents with elevated liver enzymes levels.
If elevated liver enzyme levels can predict disease course, the information could alter how and where the disease is treated, Bernstein said.
"This is a first report. We're really right now in the beginning of learning," he said.
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