• Stephanie Melquist, Kayla Estepp, Yauheni Aleksandrovich, Angela Lee, Andrea Beiseker, Farid Saei Hamedani, and John Bassett.
• University of North Dakota School of Medicine and Health Sciences, Department of Internal Medicine.
• Medicine (Baltimore). 2020 Oct 23; 99 (43): e22818e22818.

IntroductionSevere acute respiratory syndrome corona virus 2 (SARS-CoV-2) responsible for the COVID-19 pandemic has spread from Wuhan, China in December, 2019 to 216 countries and territories as of September 10, 2020 with 27.74 million cases and 899,911 confirmed deaths. The spectrum of disease is most commonly seen as a viral pneumonia with high grade fevers, shortness of breath, dry cough, and chest pain with radiologic evidence of bilateral, interstitial, ground glass opacities, and peripheral lung consolidation. Liver chemistries are frequently abnormal, with transaminases shown to be one-two times the upper limit of normal in most instances. The full spectrum of gastrointestinal involvement of the SARS-CoV-2 infection has yet to be fully seen.Patient concerns: We present a case of a young woman with SLE who developed severe abdominal pain, nausea and vomiting, rapidly progressing to acute hepatic failure and tested positive for SARS-CoV-2 infection. She had no respiratory symptoms.DiagnosisA thorough work-up of acute liver failure including liver biopsy confirmed acute hepatitis with viral like changes. Common viral causes of liver failure were ruled out. The patient had no recent travel history.InterventionsThe patient was started on hydroxychloroquine due to SLE, treated with N-Acetyl-Cysteine, and methylprednisolone.OutcomesThe patient improved with resolution of encephalopathy and normalization of her liver chemistries without any development of respiratory illness.ConclusionThis case details a unique presentation of likely SARS-CoV-2 infection. Until now, the literature has primarily described a respiratory illness and liver injury with mild transaminase elevations. Significant liver injury progressing to acute liver failure should be considered in those with SARS-CoV-2 infection.

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