Gastrointestinal and liver manifestations of COVID-19

A case-control autopsy series of liver pathology associated with novel coronavirus disease (COVID-19)

BACKGROUND

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) responsible for coronavirus disease 2019 (COVID-19) is most well-known for causing pulmonary injury, a significant proportion of patients experience hepatic dysfunction. The mechanism by which SARS-CoV2 causes liver injury is not fully understood. The goal of this study was to describe the hepatic pathology in a large cohort of deceased patients with COVID-19 as compared to a control group of deceased patients without COVID-19.

METHODS

Consented autopsy cases at two institutions were searched for documentation of COVID-19 as a contributing cause of death. A group of consecutive consented autopsy cases during the same period, negative for SARS-CoV-2 infection, was used as a control group. The autopsy report and electronic medical records were reviewed for relevant clinicopathologic information. H&E-stained liver sections from both groups were examined for pertinent histologic features. Select cases underwent immunohistochemical staining for CD 68 and ACE2 and droplet digital polymerase chain reaction (ddPCR) assay for evaluation of SARS-CoV2 RNA.

RESULTS

48 COVID-19 positive patients (median age 73, M:F 3:1) and 40 COVID-19 negative control patients (median age 67.5, M:F 1.4:1) were included in the study. The COVID-19 positive group was significantly older and had a lower rate of alcoholism and malignancy, but there was no difference in other comorbidities. The COVID-19 positive group was more likely to have received steroids (75.6 % vs. 36.1 %, p < 0.001). Hepatic vascular changes were seen in a minority (10.6 %) of COVID-19 positive cases. When all patients were included, there were no significant histopathologic differences between groups, but when patients with chronic alcoholism were excluded, the COVID-19 positive group was significantly more likely to have steatosis (80.9 % vs. 50.0 %, p = 0.004) and lobular inflammation (45.7 % vs. 20.7 %, p = 0.03). Testing for viral RNA by ddPCR identified 2 of the 18 (11.1 %) COVID-19 positive cases to have SARS-CoV-2 RNA detected within the liver FFPE tissue.

CONCLUSIONS

The most significant findings in the liver of COVID-19 positive patients were mild lobular inflammation and steatosis. The high rate of steroid therapy in this population may be a possible source of steatosis. Hepatic vascular alterations were only identified in a minority of patients and did not appear to play a predominant role in COVID-19 mediated hepatic injury. Low incidence of SARS-CoV-2 RNA positivity in liver tissue in our cohort suggests hepatic injury in the setting of COVID-19 may be secondary in nature.

Characterization of adverse events to hydroxychloroquine, ivermectin, azithromycin and tocilizumab in patients hospitalized due to COVID-19 in a Peruvian Social Health Insurance hospital

OBJECTIVE.

To characterize the adverse events (AEs) related to the off-label use of hydroxychloroquine (HQ), azithromycin (AZI), tocilizumab (TOB) and ivermectin (IVM) for the treatment of COVID-19 in hospitalized patients.

MATERIALS AND METHODS.

We conducted a secondary cross-sectional analysis of the Peruvian Social Health Insurance (EsSalud) pharmacovigilance system database of AE notifications to HQ, AZI, TOB and IVM in the Edgardo Rebagliati Martins National Hospital from April to October 2020. Information was collected from digital medical records. We estimated AE reporting rates and evaluated their characteristics by drug type, time of occurrence, type by the affected organ-system, severity and causality.

RESULTS.

We identified 154 notifications describing a total of 183 AE possibly related to HQ, AZI, TOB and IVM; the reporting rate was 8%. The median time of AE occurrence was 3 days (IQR: 2-5). Most were cardiovascular events; prolongation of the QT interval was the most frequent. Hepatobiliary AEs were mainly associated with TOB. Most cases were moderate, however, 10.4% were severe.

CONCLUSIONS.

We found AEs potentially associated with the use of HQ, AZI, TOB and IVM against COVID-19; cardiovascular events were the most frequent. Although AZI, HQ and IVM have known safety profiles, their use against COVID-19 could increase the occurrence of AE due to the risk factors inherent to this infection. Surveillance systems must be improved, especially those for TOB.

Effect of COVID-19 on Serum Activity of Liver Enzymes: Is This Associated with Severity and Mortality Rate?

Introduction Coronavirus disease 2019 (COVID-19) is a viral infection caused by a novel coronavirus known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease raises an enormous public health challenge for the international community. Liver enzymes have been reported to be frequently elevated in hospitalized patients with severe COVID-19 disease.

Materials and Methods This article is a narrative review of abnormal liver tests and liver injury as a manifestation of progression to severe pneumonia. We collected data from the PubMed database (National Library of Medicine, Bethesda, Maryland, United States). We used the search term “abnormal liver test” and relevant records were measured. The review article was organized thematically.

Results This narrative review aims to summarize the available clinical data on abnormal liver enzymes in coronavirus infection and its association with the risk of mortality, severer pneumonia, and systemic inflammation. Some clinical studies refer to abnormal liver tests and liver injury as a manifestation of progression to severe pneumonia. Recent research verified the relationship between hepatic liver enzyme activities and liver damage in patients with COVID-19, which suggested that it might reflect the infection severity and the mortality risk. Thus, this review investigated the correlation between liver serum enzymes level and the severity of COVID-19 patients, by reviewing investigating the relationship between the illness severity in COVID-19 patients with abnormal liver tests, liver pathology, and markers of inflammation.

Conclusion In the current pandemic of SARS-CoV-2, abnormalities of liver enzyme tests were commonly observed in patients with COVID-19. However, because of multiorgan damages that observed in COVID-19 patients, various issues should be considered such as the pathology and pathophysiology of the liver tissue, especially on the activation process of the immune response and cytokine storm to prevent the severity of the disease.

Emergency room imaging findings in patients presenting after COVID-19 vaccination

Objectives

Data on potential side effects of COVID-19 vaccines remains limited. This study aims to evaluate the relationship between the clinical presentations and imaging findings of emergency room (ER) patients presenting with suspected side effects or complications of recent COVID-19 vaccination.

Materials and Methods

An Institutional Review Board-approved retrospective analysis of vaccinated patients who underwent imaging studies in the ER between December 2020 and August 2021 was conducted. Reports were analyzed for imaging modality, chief complaints, and imaging findings.

Results

A total of 173 studies on 161 patients were included: 73 X-rays, 57 computed tomographys, 12 magnetic resonance imagings, and 31 ultrasounds. Analysis of the 168 reports dictated in these 173 studies revealed chest pain (27%), shortness of breath (17%), headache (12.5%), fever (10%), and cough (11.9%) as the most common presenting signs/symptoms. About 57.7% of reports showed no post-vaccine complications. Of the 42.3% of reports with findings, lung opacities/consolidation (36.6%) and cervical and/or axillary adenopathy (35.2%) were most commonly seen; other major findings included saddle embolus (1.4%) and vertebral artery occlusion (1.4%).

Conclusion

Chest pain, cough, shortness of breath, and headache were the most common presenting symptoms in the ER after COVID-19 vaccination, and chest X-ray and computed tomography chest angiography were the most commonly ordered studies to assess vaccine-related complications. Lung opacities/consolidations were the most common findings. Given that vascular post-vaccine complications are considered the most dangerous and 2.8% of reports demonstrated positive vascular findings, concern for vascular complications should initiate appropriate imaging to ensure prompt diagnosis and management.

Liver and Gastrointestinal Involvement in Patients With COVID-19: A Retrospective Study

Background

Coronavirus disease 2019 (COVID-19) classically presents as a respiratory illness with fever, dry cough, and dyspnea on exertion. Along with respiratory signs and symptoms, gastrointestinal (GI) manifestations and liver injury have been recognized during the progression of the disease. This study aimed to determine the prevalence of GI symptoms and hepatic injury during COVID-19 infections and their consequences on the outcome of the disease.

Methodology

We conducted a retrospective survey of 715 participants age 16 or older diagnosed with COVID-19 and reported GI and hepatic manifestations in the Dammam Medical Complex in Dammam, Eastern Province, Saudi Arabia, from March 1, 2020, to May 31, 2020. We recorded clinical manifestations, laboratory test results, patient demographics, comorbidities, and treatments.

Results

The mean age of the study population was 46 years (88% were male, 12% were female), and 80% were non-Saudi. While most patients recovered and were discharged (n=603, 84.62%), 100 (13.99%) died due to COVID-19. Type 2 diabetes was present in 182 patients (79%) discharged and 45 patients (21%) who died. Hypertension was present in 26 (67%) discharged and 158 patients (81%) who died. Cardiovascular disease was present in 26 patients (67%) discharged and 13 (33%) who died. Chronic kidney disease was found in 11 patients (61%) discharged and six (33%) who died. Diarrhea was present in 11% of patients, nausea in 8%, and vomiting in 9% of patients. Twenty percent of patients had at least one GI symptom. Only 10% of those who died had GI symptoms, while 88% of those discharged had GI symptoms. Serum levels of alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, and γ-glutamyl transpeptidase were generally higher in the patients who died than in those who were discharged.

Conclusions

We noted an increase in at least one liver enzyme with no clinically significant acute liver injury or cases of acute liver failure as sequelae of COVID-19. However, the presence of injury at the time of admission resulted in a significantly higher mortality rate. Only a small number of patients infected with COVID-19 exhibited GI manifestations. The etiology of severe acute respiratory syndrome coronavirus 2-related GI involvement is due to multiple factors. It is not yet fully understood if GI manifestations are clinical signs of high viral loads or another physiological process. The clinical manifestation and laboratory test results indicate that COVID-19 impacts the hepatic system and GI tract, indicating that COVID-19 infection may risk liver and GI tract injury.

COVID 19 in pregnant women and neonates: Clinical characteristics and laboratory and imaging findings. An overview of systematic reviews

Introduction: SARS-CoV-2 infection in the perinatal period may be associated with an increased risk of morbidity and mortality in both the mother and the neonate. Objective: To describe the clinical characteristics and, laboratory and imaging findings in pregnant women with COVID-19 and their newborns. Materials and methods: We searched PubMed, Scopus, Web of Science, and Cochrane databases for systematic reviews published between February 1, 2020, and May 30, 2021, describing clinical characteristics and laboratory and imaging (chest) findings in pregnant women with COVID-19 and their newborns; there were no language restrictions. Data were reanalyzed by means of Bayesian meta-analysis using Markov Chain Monte Carlo methods. The study protocol is registered in PROSPERO under code CRD42020178329. Results: Six systematic reviews were retrieved (for a total of 617 primary studies). A narrative synthesis of the proportions of signs, symptoms, and imaging and laboratory findings of both mothers and neonates was performed. The Odds ratios (OR) between pregnant women with and without COVID-19 were as follows: fetal well-being involvement: 1.9 (95%CI:1.09-3.63); stillbirth: 1.73 (95%CI:1.01-2.94); preterm birth: 1.77 (95%CI:1.25-2.61); maternal admission to the intensive care unit (ICU): 6.75 (95%CI:1-31.19). Regarding symptomatology, the following OR was obtained for myalgia between pregnant women and non-pregnant women with COVID-19: 0.67 (95% CI:0.51-0.93). Conclusions: Cough, fever, dyspnea, and myalgia are the most common symptoms in pregnant women with COVID-19; in addition, there is a higher risk of admission to the ICU. Regarding complementary testing, the most frequent alterations are lymphopenia and the evidence of lesions in chest imaging studies. The presence of COVID-19 in pregnant women is associated with premature birth. It seems that SARS-CoV-2 infection in neonates is not serious and the risk of vertical transmission is low, since no data about congenital malformations attributable to the virus were found.

Effects of Ultramicronized Palmitoylethanolamide (um-PEA) in COVID-19 Early Stages: A Case–Control Study

Ultramicronized palmitoylethanolamide (um-PEA), a compound with antioxidant, anti-inflammatory and neuroprotective properties, appears to be a potential adjuvant treatment for early stages of Coronavirus disease 2019 (COVID-19). In our study, we enrolled 90 patients with confirmed diagnosis of COVID-19 that were randomized into two groups, homogeneous for age, gender and BMI. The first group received oral supplementation based on um-PEA at a dose of 1800 mg/day for a total of 28 days; the second group was the control group (R.S. 73.20). At baseline (T0) and after 28 days of um-PEA treatment (T1), we monitored: routine laboratory parameters, inflammatory and oxidative stress (OS) biomarkers, lymphocytes subpopulation and COVID-19 serological response. At T1, the um-PEA-treated group presented a significant reduction in inflammation compared to the control group (CRP p = 0.007; IL-6 p = 0.0001; neutrophils to lymphocytes ratio p = 0.044). At T1, the controls showed a significant increase in OS compared to the treated group (FORT p = 0.05). At T1, the um-PEA group exhibited a significant decrease in D-dimer levels (p = 0.0001) and higher levels of IgG against SARS-CoV-2 (p = 0.0001) compared to the controls. Our data demonstrated, in a randomized clinical trial, the beneficial effects of um-PEA in both asymptomatic and mild-symptomatic patients related to reductions in inflammatory state, OS and coagulative cascade alterations.

GASTROINTESTINAL COMPLICATIONS OF CORONAVIRUS DISEASE (COVID-19)

Background:

It is currently understood that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) directly enters target cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor. Accordingly, tissues with high expression levels of ACE2 are more susceptible to infection, including pulmonary alveolar epithelial cells, small intestine enterocytes, cholangiocytes, and vascular endothelial cells. Considering the atypical manifestations of COVID-19 and the challenges of early diagnosis, this review addresses the possible gastrointestinal complications of the disease.

Method:

The phrase “Gastrointestinal complication of COVID” was searched in the PubMed, Medline, and SciELO databases. Due to the heterogeneity of the studies included in the present review, a narrative synthesis of the available qualitative data was performed.

Result:

The literature search retrieved 28 articles, primarily case reports and case series, for the qualitative analysis of gastrointestinal complications of COVID-19, in addition to two retrospective cohort and one case-control. The studies focused on hemorrhagic, thrombotic, ischemic, and perforation complications, in addition to acute pancreatitis and pneumatosis intestinalis.

Conclusion:

There is a straight relationship between high expression levels of ACE2 in the gastrointestinal tract and its greater susceptibility to direct infection by SARS-CoV-2. So, it is important to consider the gastrointestinal infection manifestations for early diagnosis and treatment trying to avoid more serious complications and death.

COVID-19 and the liver: A brief and core review

Coronavirus disease 2019 has a wide range of clinical spectrum from asymptomatic infection to severe infection resulting in death within a short time. Currently, it is known that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) does not only cause a respiratory tract infection but a more complicated disease that can lead to multiple system involvement including the liver. Herein, we evaluate the epidemiology, the impact of liver injury/ dysfunction on disease prognosis, the pathophysiological mechanisms and management of liver injury. More than one-fourth of the patients have abnormal liver function tests, mostly a mild-to-moderate liver dysfunction. Liver injury is significantly associated with a poor clinical outcome. Direct cytotoxic effect of SARS-CoV-2, the immune response (“cytokine storm”), the complications related to the disease, and drugs used in the treatments are the pathophysiological mechanisms responsible for liver injury. However, the exact mechanism is not yet clearly explained. The binding of SARS-CoV-2 to the angiotensin-converting enzyme 2 receptors and entering the hepatocyte and cholangiocytes can cause cytotoxic effects on the liver. Excessive immune response has an important role in disease progression and causes acute respiratory distress syndrome and multi-organ failures accompanied by liver injury. Treatment drugs, particularly lopinavir/ritonavir, remdesivir and antibiotics are a frequent reason for liver injury. The possible reasons should be meticulously investigated and resolved.

Impact of COVID-19 pandemic on liver, liver diseases, and liver transplantation programs in intensive care units

Emerging worldwide data have been suggesting that coronavirus disease 2019 (COVID-19) pandemic consequences are not limited to the respiratory and cardiovascular systems but encompass adverse gastrointestinal manifestations including acute liver injury as well. Severe cases of liver injury associated with higher fatality rates were observed in critically ill patients with COVID-19. Intensive care units (ICU) have been the center of disposition of severe cases of COVID-19. This review discusses the pathogenesis of acute liver injury in ICU patients with COVID-19, and analyzes its prevalence, consequences, possible drug-induced liver injury, and the impact of the pandemic on liver diseases and transplantation programs.

Critically Ill COVID-19 Patient with Chronic Liver Disease - Insights into a Comprehensive Liver Intensive Care

The novel coronavirus-related coronavirus disease 2019 (COVID-19) pandemic has been relentless in disrupting and overwhelming healthcare the world over. Clinical outcomes of COVID-19 in patients with chronic comorbidities, especially in those with metabolic syndrome, are well documented. Chronic liver disease and cirrhosis patients are a special sub-group, among whom the management of COVID-19 is challenging. Understanding the pathophysiology of COVID-19 in patients with cirrhosis and portal hypertension improves our identification of at-risk patients for disease progression that will further help compartmentalize generalized and specialized treatment options in this special patient group. In this exhaustive review, we critically review the impact of COVID-19 on the liver and in chronic liver disease and cirrhosis patients. We further discuss common features associated with the pathophysiology of COVID-19 and cirrhosis, based on the renin-angiotensin system and deliberate current literature on guidelines for the treatment of COVID-19 and extrapolate the same to the cirrhosis population to provide a concise and stepwise, evidence-based management for cirrhosis patients with severe and critical COVID-19. There are no specific management guidelines for cirrhosis patients with COVID-19 and current recommendations for treatment are as per guidelines for general population. Nevertheless, specific issues like avoiding corticosteroids in decompensated patients with variceal bleeding, suspected sepsis, high grade hepatic encephalopathy and acute kidney injury, use of early mechanical ventilation strategies in those with severe ascites and hepatopulmonary syndrome, avoidance of remdesivir in advanced liver disease, and application of liver-specific severity scores for prognostication and identification of futility need to be highlighted.

Ultramicronized Palmitoylethanolamide (um-PEA): A New Possible Adjuvant Treatment in COVID-19 patients

The Coronavirus Disease-19 (COVID-19) pandemic has caused more than 100,000,000 cases of coronavirus infection in the world in just a year, of which there were 2 million deaths. Its clinical picture is characterized by pulmonary involvement that culminates, in the most severe cases, in acute respiratory distress syndrome (ARDS). However, COVID-19 affects other organs and systems, including cardiovascular, urinary, gastrointestinal, and nervous systems. Currently, unique-drug therapy is not supported by international guidelines. In this context, it is important to resort to adjuvant therapies in combination with traditional pharmacological treatments. Among natural bioactive compounds, palmitoylethanolamide (PEA) seems to have potentially beneficial effects. In fact, the Food and Drug Administration (FDA) authorized an ongoing clinical trial with ultramicronized (um)-PEA as an add-on therapy in the treatment of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. In support of this hypothesis, in vitro and in vivo studies have highlighted the immunomodulatory, anti-inflammatory, neuroprotective and pain-relieving effects of PEA, especially in its um form. The purpose of this review is to highlight the potential use of um-PEA as an adjuvant treatment in SARS-CoV-2 infection.

COVID-19: Specific and Non-Specific Clinical Manifestations and Symptoms: The Current State of Knowledge

Coronavirus disease 2019 (COVID-19), due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has become an epidemiological threat and a worldwide concern. SARS-CoV-2 has spread to 210 countries worldwide and more than 6,500,000 confirmed cases and 384,643 deaths have been reported, while the number of both confirmed and fatal cases is continually increasing. COVID-19 is a viral disease that can affect every age group—from infants to the elderly—resulting in a wide spectrum of various clinical manifestations. COVID-19 might present different degrees of severity—from mild or even asymptomatic carriers, even to fatal cases. The most common complications include pneumonia and acute respiratory distress syndrome. Fever, dry cough, muscle weakness, and chest pain are the most prevalent and typical symptoms of COVID-19. However, patients might also present atypical symptoms that can occur alone, which might indicate the possible SARS-CoV-2 infection. The aim of this paper is to review and summarize all of the findings regarding clinical manifestations of COVID-19 patients, which include respiratory, neurological, olfactory and gustatory, gastrointestinal, ophthalmic, dermatological, cardiac, and rheumatologic manifestations, as well as specific symptoms in pediatric patients.