Acute icteric hepatitis as the first isolated symptom of COV
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Since December 2019, more than 150 million people have been infected by the SARS-CoV-2 worldwide and >3 million patients have died. Controlling the pandemic is difficult because exhaustive identification of cases is complex, as patients with COVID-19 might be asymptomatic or present with extrarespiratory symptoms, such as liver injury. It has been reported that 22.5%–46.2% of patients have moderate elevation of liver enzymes.

To the knowledge, acute hepatitis has never been described as an isolated symptom of COVID-19 in a previously healthy patient. Authors, hereby, report the case of a patient with COVID-19 whose first clinical presentation was acute icteric hepatitis, several days before the development of others symptoms.

A previously healthy 53-year-old man presented to the emergency department (ED) with 3 days of fatigue and jaundice history, including scleral icterus and dark urine. He reported no other symptoms, particularly no fever, cough, shortness of breath, sore throat, rhinorrhea, myalgia, headache, chest pain, anosmia, dysgeusia or digestive trouble. He did not take any medication or use any drugs. He had not recently travelled or declared any contact with sick people. On presentation, he was afebrile (36.3°C) and his vital signs were normal. His respiratory rate was 16 breaths/min, his oxygen saturation was 99% on room air and his lung fields were clear on auscultation. Apart from jaundice, the physical examination was unremarkable.

Complete blood count was normal including absolute lymphocyte count (1650 cells/mm3), and inflammatory markers (C reactive protein and procalcitonin) were negative. Liver function tests read as follows: aspartate aminotransferase 1366 IU/L, alanine aminotransferase 2495 IU/L, alkaline phosphatase 258 IU/L, g-glutamyl transferase 311 IU/L, total bilirubin 2.7 mg/dL, direct bilirubin 1.7 mg/dL and prothrombin time more than 100%. Abdominal ultrasound with Doppler showed normal liver and gallbladder with a patent portal and hepatic circulation.

As the patient spent the night in the ED observation unit, a nasopharyngeal swab was done and RT-PCR was negative for COVID-19. The following serological tests were performed and all came back negative (no antibodies or immunity): hepatitis A, B, C, D, E, EBV, CMV, HIV, HSV1, HSV2, HHV6, HHV8, parvovirus B19, leptospirosis and listeria. Blood cultures and screening for autoimmune hepatitis markers (antinuclear, antisoluble liver antigen, antismooth muscle, antimitochondrial, antiliver cytosol, antiliver kidney microsomal and antigastric parietal cell antibodies) were also negative.

The patient was discharged home without any specific treatment with an outpatient follow-up. Two days later, he developed a fever up to 40°C. Then 4 days later, he presented with sudden anosmia. He immediately performed a SARS-CoV-2 antigen test which confirmed COVID-19. After an uncomfortable week (fever, fatigue, myalgia and headache), the patient totally recovered. Liver function tests gradually improved until they completely returned to normal at 2 months.