Liver Injury in Patients with COVID-19 without Underlying Liver Disease

SARS-CoV-2 shows a high affinity for the ACE-2 receptor, present on the epithelial cells of the upper and lower respiratory tract, within the intestine, kidneys, heart, testes, biliary epithelium, and—where it is particularly challenging—on vascular endothelial cells. Liver involvement is a rare manifestation of COVID-19. Material and Methods: We reviewed 450 patients admitted due to the fact of SARS-CoV-2 infection (COVID-19) including 88 with liver injury. Based on medical history and previous laboratory test results, we excluded cases of underlying liver disease. The analysis involved a clinical course of COVID-19 in patients without underlying liver disease as well as the type and course of liver injury. Results: Signs and symptoms of liver injury were present in 20% of patients, mostly presenting as a mixed-type pattern of injury with less common cases of standalone hepatocellular (parenchymal) or cholestatic injury. The liver injury symptoms resolved at the end of inpatient treatment in 20% of cases. Sixteen patients died with no cases where liver injury would be deemed a cause of death. Conclusions: (1) Liver injury secondary to COVID-19 was mild, and in in 20%, the signs and symptoms of liver injury resolved by the end of hospitalization. (2) It seems that liver injury in patients with COVID-19 was not associated with a higher risk of mortality. (3) The underlying mechanism of liver injury as well as its sequelae are not fully known. Therefore, caution and further monitoring are advised, especially in patients whose liver function tests have not returned to normal values.

Assessment of Plasma Vitronectin as Diagnostic and Prognostic Marker of Hepatocellular Carcinoma in Patients with Hepatitis C Virus Cirrhosis

Background: hepatitis C is an inflammatory liver disease caused by the hepatitis C infection (HCV), and without treatment, almost 50% will progress to liver cirrhosis. Hepatocellular carcinoma (HCC) is the most frequent type of primary liver cancer and the fourth leading cause of cancer-related mortality. Aim of the study: the objective of this study was to evaluate the serum level of vitronectin (VTN) compared to AFP and determine their role as diagnostic and prognostic markers of HCV-related liver diseases. Subject and Methods: this study involved 52 HCV patients from which 26 patients were cirrhotic, and 26 patients had HCC (on top of hepatitis C virus-related cirrhosis) plus 10 healthy people as a control group. It was carried out in Gastroenterology and Hepatology Unit, Internal Medicine Department, Zagazig University Hospitals, Egypt. All individuals in this study were subjected to physical examination, full history taking, liver function tests, assessment of serum levels of Vitronectin (VTN) and alpha-fetoprotein (AFP) before and after the intervention within three months. Results: serum level of vitronectin increased significantly in cirrhosis patients and HCC patients than controls (p = 0.0041), (p < 0.001), respectively, and in HCC than cirrhosis patients (p < 0.001). Significant positive correlations were observed between levels of serum VTN and AFP in all HCV patients as well as cirrhotic patients (p < 0.001, p = 0.011, respectively). On the contrary, VTN and AFP didn’t show a significant correlation in HCC patients’ group. Moreover, the median serum level of VTN decreased significantly after treatment in patients with HCC (p < 0.001). At cut-off 38.5 ng/mL for AFP it shows sensitivity 80.8%, specificity 76.9% to differentiate HCC from cirrhosis cases. While VTN shows 84.6% sensitivity, 96.2% specificity at cut-off 26.5 μg/mL. Regarding clinicopathological characteristics and VTN levels, half of patients were stage B, 63.9% had tumor size >3 cm, 84.6% had more than one focal lesion. Conclusions: these results may allow one to speculate a potential role of Vitronectin in diagnosis and prognosis of HCC on top of cirrhosis related to HCV infection in addition to AFP and US and CT.

In pursuit of incorporation of markers of oxidative stress in traditional biochemical panels in clinical Chemistry: A risk assessment step in diagnosis and biotherapy

Chemical pathology (clinical chemistry/biochemistry) is the branch of laboratory medicine concerned with the detection of alterations in the chemical constituents and biochemical mechanisms, which ensure health, culminating in disease. The disease itself is a pattern of response to some insult or injury resulting in a disturbed function or structure. It is often difficult to ascertain precisely the point of transition from health to a disease state. Pathological changes, including metabolic and molecular perturbations, with the potential to progress to clinical disease, are also present in healthy populations, noteworthy are the reactive oxygen species such as hydroxyl radicals with the propensity to cause oxidative DNA damage. Biochemical profiles or panels such as liver function tests, renal function tests, bone profile, lipid profile, acid-base, and critical care have served as biomarkers employed in indicating the presence of or measuring the progress of the disease, as well as the effect of treatment. Oxidative stress, an imbalance between bio-available antioxidants and reactive species, is now widely recognized as accompanying most pathological states. Hence, the exclusion of antioxidant components in biochemical profiles appears a grave oversight. Basic components of the antioxidant system, glutathione (GSH), zinc, uric acid, ascorbic acid, and α-tocopherol, may be selected for incorporation. GSH is particularly important; as a scavenger for damaging oxidative intermediates in cells, it promises to be a good predictor of disease progression and prognosis. Including the antioxidant component into traditional profiles may aid physicians in more confidently ruling out disease, enabling further investigations, and/or reassuring patients. It is proposed that redefining the traditional profiles in chemical pathology by incorporating the indexes of the antioxidant system promises considerable improvement in the risk assessment process, in disease detection and recognition of the threshold of clinical concern in disease management and biotherapy.

Evaluation of the Effect of COVID-19 Pneumonia on Kidney Function

Background: Severe acute respiratory tract infection, pneumonia, kidney failure, and multi-organ failure may develop in cases that result in death due to COVID-19. It is emphasized that the awareness of healthcare professionals about kidney functions should be increased in cases of COVID-19 pneumonia. Quick and effective steps can be taken in the treatment of COVID-19 pneumonia with the controlling approach of nurses to changes in kidney functions. Method: This study was carried out retrospectively to evaluate the kidney functions of patients diagnosed with COVID-19 pneumonia who were hospitalized in the pandemic hospital. Hospital and nurse observation files of 120 patients who were introduced to COVID-19 pneumonia between 1 May and 30 November 2020 were examined. Categorical data were described as continuous data as median with interquartile range (IQR) and percentages (%). Results: In total, 30 patients (25.0%) required mechanical ventilation, Overall, 39.1% (47) developed acute kidney injury during hospitalization, out of which 10.8% reached stage 1, 15.0% reached stage 2, and 13.3% reached stage 3. Dialytic support was required for seven (17.1% of all patients). COVID-19 pneumonia patients had higher levels of aspartate aminotransferase (AST) (55.02±58.04), alanine aminotransferase (ALT) (74.07±140.94), lactate dehydrogenase (LDH) (483.48±477.51), C-reactive protein (CRP) (88.02±72.17), D-dimer (1023±1548.01), procalcitonin (3.70± 6.52). In addition, a proportion of COVID-19 pneumonia patients but no non-COVID-19 pneumonia patients had abnormally increased AST (10.0-274.0), ALT (7.0-854.0), LDH (164-3547), CRP (5.10- 310.90), D-dimer (151-6212), procalcitonin (195-433). SpO2 of COVID-19 pneumonia patients had 78-97%, patients who need dialysis treatment due to pneumonia, follow-up coagulation profile (Procalcitonin, LDH, D-dimer), liver-renal function (ALT, AST, Creatine, Urea, Albumin), assessing signs of DVT and psychological support. 89 patients (74.2%) received corticosteroid, 73 patients (60.8%) received expectorant, 61 patients (50.8%) received vitamin C or B complex, 110 patients (91.7%) received anticoagulant and 73 patients (60.8%) received antibiotics. All of the COVID-19 pneumonia patients received the antiviral drug. Conclusion: As the disease progresses, differences in laboratory results and radiological findings may indicate that some complications have developed. COVID-19 pneumonia draws attention with liver function tests such as AST / ALT, LDH, infection markers in the blood, and the high rate of coagulation factors such as PCT and D-dimer during the hospital stay. The fact that these elevated values ​​may cause necrosis in the kidneys also brings about the truth. Careful monitoring of laboratory findings such as elevation of AST / ALT, LDH, PCT, and D-dimer in patients who develop pneumonia due to COVID-19 may provide early action for kidney damage.

Autoimmune Hepatitis and Primary Biliary Cholangitis Overlap in a Patient with Systemic Lupus Erythematosus and Rheumatoid Arthritis Overlap (Rhupus) - An Unusual Association

The diagnosis of overlap syndrome involving systemic lupus erythematosus (SLE) and autoimmune hepatitis (AIH) isn’t easily established due to its similar clinical presentations and biochemical features to those of lupus hepatitis. The term overlap syndrome is typically utilized in the context of overlap of autoimmune hepatitis with PSC (primary sclerosing cholangitis) or PBC (primary biliary cholangitis). Few rare cases of AIH complicated by SLE are reported within the literature. Overlapping of SLE and AIH should be suspected when patients with SLE have abnormal liver function tests or AIH patients present with a rash. Liver biopsy plays a really important role in establishing the medical diagnosis of SLE with liver impairment or overlap with AIH. The prompt diagnosis and adequate treatment plan can improve the disease outcome. Key words: autoimmune hepatitis, primary biliary cholangitis, systemic lupus erythematosus, overlap syndrome.

Extra-Intestinal Manifestations of Celiac Disease: What Should We Know in 2022?

Celiac disease (CD) is a chronic, small-intestinal, immune-mediated enteropathy due to gluten exposition in genetically predisposed individuals. It occurs in about 1% of the population and often remains an underdiagnosed condition. This could be due to the fact that the adult population often lacks the classical signs and symptoms of CD, manifesting only atypical symptoms. In this review we analyzed the main extra-intestinal manifestations of CD which include cutaneous and endocrinological disorders, abnormal liver function tests, and neuropsychiatric features. When CD is not diagnosed and therefore is not treated with a gluten-free diet (GFD), it can predispose to severe complications, not only gastrointestinal. Thus, it is important for clinicians to quickly recognize the atypical manifestations of CD, considering that an early diagnosis can significantly impact on a patient’s prognosis.

Alterations of liver function tests in diabetic obese and nonobese individuals

Introduction and Aim: India has emerged as the diabetes capital in Southeast Asia having around 74 million with diabetes, with a prevalence of 9.8% in 18–99 years of age. In type 2 diabetes mellitus, triglycerides get deposited in liver thus altering its structure and function, which is the feature of nonalcoholic fatty liver disease. This study was undertaken to study the alterations in liver function tests in obese and nonobese diabetic individuals. Materials and Methods: The Department of Biochemistry at Sri Ramachandra Institute of Higher Education and Research was chosen to conduct the retrospective study on 200 diabetic individuals from September 2019 to February 2020. The data obtained were serum liver function tests, HbA1c, plasma glucose and lipid profile. Before the study ethics approval was obtained from the Institutional Ethics Committee for studies involving human participants. The obtained data were subjected to statistical analysis using SPSS version 16 and a P value less than 0.05 was considered statistically significant. Results: Transaminases and ALP were significantly altered in obese diabetics; were positively correlated with bilirubin. TGL was negatively correlated with AST/ALT ratio. Conclusion: Liver enzymes and bilirubin were altered in obese diabetics. Measurement of liver function biomarkers are cost effective diagnostic markers of non-alcoholic fatty liver disease.

Study of dynamic changes in the parameters of liver function tests in COVID-19 patients: A hospital-based study in Eastern Nepal

Background: COVID-19 has become a focus of healthcare practitioners worldwide after it was declared as a global pandemic. Although SARS-CoV-2 is primarily affecting the respiratory system, numerous studies have documented its impact on other organ systems, including the liver. This study aims to assess liver function in COVID-19 patients in light of SARS-CoV-2's extremely infectious and pathogenic character. Material and methods: It was a hospital-based retrospective study conducted between January 1, 2021, and July 31, 2021, using data from the Department of Biochemistry at Birat Medical College Teaching Hospital in Nepal. Age, gender, total protein, albumin, AST, ALT, and the AST/ALT ratio were all measured. Results: The median age of COVID-19 patients was 36 years (CI, 25–51), 60 patients (60.0%) were male, 31 patients (31.0%) were obese, and 20 patients (20%) had comorbidities, such as hypertension (14%) and diabetes mellitus (6.0 %). Compared to the non-critical group, the mean values of ALT, AST, ALP, GT, LDH, TBIL, and DBIL were significantly higher in the severe group. On the other hand, total protein and albumin were significantly lower in the severe group than the non-severe group. Conclusion: In COVID-19, aberrant liver function, primarily AST increase, appears to be common. Therefore, direct viral hepatotoxicity during a systemic viral infection must be considered, as well as the possibility of sepsis or worsening of existing liver disease.

Aortic root aneurysm with right atrial clot: a rare combination

Though the incidence of aneurysms involving the aortic root and/or ascending aorta is common, the combination of aortic root aneurysm and the right atrial clot is extremely rare. No such case is reported in literature till date. This case report presents a 52-year gentleman who came to our emergency department with complaints of breathlessness, abdominal distention, pedal swelling, and decreased urine output with extremely poor general condition. After hemodynamic stabilization and preoperative optimization and workup, he was managed with Bentall procedure with right atrial clot removal. The immediate postoperative course was normal except for deranged liver function tests. The patient was discharged on postoperative day ten.

Necrotising Otitis Externa Antibiotic therapy complications: A retrospective cohort analysis

Introduction: Necrotising otitis externa (NOE) is a serious, progressive infection of the external ear canal. If untreated, it can invade into temporal bone, skull-base and surrounding tissue resulting in cranial nerve palsies, neurological infections and death. Patients present with unremitting, severe otalgia, otorrhoea and oedematous ear canals containing granulation. Surgery has a limited role; the mainstay of treatment involves a long course of intravenous antibiotics. Currently, there is no data on the complications of antibiotic treatment for NOE. This project aims to provide evidence on the nature/frequency of severe treatment-related complications requiring a change in antibiotic regime. Methods: A retrospective 5-year cohort analysis was performed on 64 patients who were treated for confirmed NOE with intravenous antibiotic therapy. Clinical notes, blood results and antibiotic prescriptions were documented and analysed. Results: Average duration of treatment was 11 weeks (range=38 weeks). There was an average of 2.1 antibiotic regimes per patient with 10 cases requiring inpatient admission due to treatment-related complications. 63% of treatment changes were directly related to adverse effects of intravenous antibiotics. Drug allergy/intolerance (n=18) and clinical deterioration i.e. Lack of symptomatic improvement and/or worsening inflammatory markers (n=18), were the most common reasons for antibiotic change. Neutropenia, deranged liver function tests and acute kidney injury were also recognised adverse effects of treatment. Conclusion: This study provides the first evidence on the notable frequency of antibiotic-related complications in NOE patients. Larger, multicentre studies are required in the future to validate our findings and will better inform both clinicians and patients of the risks of treatment.