Post-COVID-19 cholangiopathy

In our clinical experience with the Gamma variant in Brazil, we have come across many cases of this novel clinical entity. There was one case in 2020 that has left a mark in our practice, published in the beginning of 2021 in Portuguese (1). A 63-year-old male previously healthy patient developed a severe case of coronavirus disease 2019 (COVID-19) respiratory disease, needing prolonged mechanical ventilation and high-dose vasopressor drugs. He was admitted to the hospital on April 27, 2020. He was treated with multiple antibiotics during his stay, the last ones were an association of imipenem, polymyxin B and amikacin for a New Delhi metallo-beta-lactamase (NDM) Pseudomonas aeruginosa infective endocarditis. He underwent an endoscopic retrograde cholangiopancreatography (ERCP), which found a choledochal cast, composed of microlithiasis in the pathology report. He also underwent a percutaneous transhepatic cholangiography, which showed sclerosing cholangitis associated with intrahepatic lithiasis. He was discharged on September 25, 2020 with liver transplantation referral. After a couple of weeks of the hospital discharge, he was readmitted with a new severe sepsis, and the family opted for palliative care, and died not long afterwards. We believe this might be the first case reported of this entity, with extensive workup, including ERCP and percutaneous transhepatic cholangiography (PTHC), showing the presence of casts and lithiasis in the intra and extra-hepatic biliary tract, which makes this case unique. As based in the article by Roth et al. (2), we have put together a table summarizing our data (Table 1).

COVID-19 infection might cause liver injury, which is generally mild and transient. Although, in more severe cases, the patients might develop an entity entitled “post-COVID-19 cholangiopathy”. In 2021, two articles published in the American Journal of Gastroenterology discussed in total 15 cases of this disease (2,3). The case described had a cast removed in ERCP and we found one case similar to ours published in 2022 (4). It has been suggested that the diagnosis and management of this disease might demand an ERCP, especially if a dilated choledocus is identified in imaging studies (5,6). An actual cause is yet to be determined, but it is believed that it might be secondary to infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus or by drug-induced liver injury, since these patients sometimes use ketamine and carbapenems for long periods of time (7). Since we know so little of this entity, diagnosis and treatment for this condition are continuously revised as per available information. Symptoms, clinical signs, laboratorial manifestations, and imaging findings of the post-COVID-19 cholangiopathy do not differ from other etiological types. An adequate treatment is yet to be determined, but it seems that liver transplantation might have good results (8-11).

In conclusion, as the COVID-19 pandemic is now transforming into an endemic, we will have to manage the long-term consequences of this infection. Liver transplantation programs will require more data in this pathology, since it seems as of right now the only adequate readily available therapy in the long term (12).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Digestive Medicine Research. The article has undergone external peer review.

Peer Review File: Available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-83/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-83/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The family of the deceased patient has verbally agreed in the reporting of this case. All clinical procedures described in this article were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The family of the deceased patient has verbally agreed in the reporting of this article.

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