A Case of Fulminant Liver Failure in a 24-Year-Old Man with Coinfection with Hepatitis B Virus and SARS-CoV-2

Abstract

Patient: Male, 24-year-old Final Diagnosis: Acute kidney injury • coagulopathy • liver failure • SARS-CoV-2 Symptoms: Cough • fever Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology • Infectious Diseases Objective: Unusual clinical course Background: Coronavirus disease 2019 (COVID-19) is a newly emerging disease that is still not fully characterized. It is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel virus that can be transmitted easily from human to human mainly by the respiratory route. Currently, there is no specific treatment for COVID-19 or a vaccine for prevention. The disease has various degrees of severity. It often presents with non-specific symptoms such as fever, headache, and fatigue, accompanied by respiratory symptoms (e.g., cough and dyspnea) and other systemic involvement. Severe disease is associated with hemophagocytic syndrome and cytokine storm due to altered immune response. Patients with severe disease are more likely to have increased liver enzymes. The disease can affect the liver through various mechanisms. Case Report: We report an unusual case of SARS-CoV-2 infection in a 24-year-old man with no previous medical illness, who presented with mild respiratory involvement. He had no serious lung injury during the disease course. However, he experienced acute fulminant hepatitis B infection and cytokine release syndrome that led to multiorgan failure and death. Conclusions: It is uncommon for SARS-CoV-2 infection with mild respiratory symptoms to result in severe systemic disease and organ failure. We report an unusual case of acute hepatitis B infection with concomitant SARS-CoV-2 leading to fulminant hepatitis, multiorgan failure, and death.

Coronavirus Disease-2019 (COVID-19) and the Liver

“…Of the five ALF cases reported, three were from the USA and one from Germany and Qatar each. [43][44][45][46][47] Two of these were young, aged 24 years and 35 years, while the other three were above 50 years of age. Most of these patients were critically ill and a single etiology could not be identified as a cause except in the patient with hepatitis B co-infection, who had acute fulminant hepatitis B infection but only mild COVID-19 pneumonia.…”

“…There is a single case report of HBV induced ALF in a patient with mild SARS-CoV-2 infection. 47 …”

The Complexity of Co-Infections in the Era of COVID-19

“…There are citations of unique co-infections of SARS-CoV-2 with other systemic viral illnesses [101][102][103][104][105][106][107][108][109][110][111]. Such coinfection was particularly of interest in the context of chronic HIV infection where persistent immunocompromise or enhanced infection susceptibility otherwise might allow for either of the infections to be more severe than not [104][105][106]112].…”

“…These studies do not, however, indicate that either of the latter infections markedly affects the other. For chronic hepatitis B patients, early reports suggest that COVID-19 increases the potential for complicating outcomes [107,108]. Others have suggested that chronic hepatitis B did not predispose patients to a more severe outcome [109].…”

Severe SARS‐CoV‐2 infection presenting with acute kidney injury and diabetic ketoacidosis complicated by pancreatitis in a 53‐year man with hypertension

“…Daily, we are witnessing different presentations of the disease. Unusual presentations have been reported in association with COVID‐19 infection, symptoms overlapping with malaria infection, 2 overlapping with HELLP syndrome, 3 seasonal illnesses like dengue fever, 4 liver failure, 5 and precipitating diabetic ketoacidosis (DKA) 6 . DKA is due to insulin deficiency, causing a counter‐regulatory mechanism to break down fatty acids, increasing the production of ketone bodies.…”