Liver transplantation for treatment of acute liver failure after COVID-19 infection and anatomopathological results
Guilherme Ferrarini1, Omar Ahmad Omar1, Kelre Wannlen Campos Silva Araujo2, Nertan Luiz Tefilli1, Igor Luna Peixoto1.
1Hepatobiliopancreatic Surgery, Hospital Evangélico Mackenzie, Curitiba, Brazil; 2General Surgery Resident, Hospital Evangélico Mackenzie, Curitiba, Brazil
Cirurgia Geral, Aparelho Digestivo e Hepatobiliopancreatica - Hospital Evangélico Mackenzie.
During the year 2019, the world experienced the beginning of a pandemic that has been lasting until the present moment. The liver is one of the organs affected by COVID-19, with transaminase elevations being the most common alteration. Cholestasis is rare, present in less than 1 percent of cases.
The aim of this article is to report the case of a 64-year-old male patient with post COVID-19 cholangiopathy.
C.S.H., male, 64 years old, admitted to a referral hospital for liver diseases and transplants, in Curitiba, Paraná, Brazil. A previously healthy patient, without any history of liver disease or alcohol consumption, with negative serology for viral hepatitis and autoimmune markers, admitted with a prolonged condition of cholestasis associated with hepatocellular dysfunction, evolving with encephalopathy after infection by COVID-19. During hospitalization, three months after infection with the new coronavirus, he developed fulminant acute liver failure according to King's College criteria. He was included in the list for liver transplantation, persisted without improvement, underwent liver transplantation with an organ from a dead donor and presented good evolution in the postoperative period. Anatomopathological analysis of the explant showed subacute cholestatic liver disease, with involvement of bile ducts and hepatocytes.
Cholangiopathy can be explained by an increased expression of receptors for COVID-19 (ACE-2) on cholangiocytes, which can lead to direct viral damage. Persistent and delayed cholestasis occurs, with elevations of bilirubin and canalicular enzymes, even after recovery of lung function and rehabilitation of these patients, and affects patients without previous liver disease. The main differential diagnosis would be sclerosing cholangitis secondary to critically ill patients (CSCP), due to similar radiological findings. However, the anatomopathological analysis of these patients shows us a new entity, due to the intense presence of cytoplasmic vacuolization of cholangiocytes and microvascular alterations not previously described in (CSCP). This cholangiopathy can lead to progression of liver damage with the potential need for liver transplantation. In the literature review carried out by the researchers in question, four reported cases of liver transplantation for post COVID cholangiopathy were found so far. It is necessary to keep looking on new clinical entities that may arise in the long term, as we become familiar with this new clinical entity.
Hospital Evangélico Mackenzie.
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