• Michele Luglio, Uenis Tannuri, Werther Brunow de Carvalho, Karina Lucio de Medeiros Bastos, Isadora Souza Rodriguez, Cintia Johnston, and Artur Figueiredo Delgado.
• Centro de Terapia Intensiva do Instituto da Crianca e do Adolescente (ICr), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, SP, BR.
• Clinics (Sao Paulo). 2020 Jan 1; 75: e2250e2250.

AbstractSARS-CoV-2 shares nearly 80% of its' genomic sequence with SARS-CoV and MERS-CoV, both viruses known to cause respiratory symptoms and liver impairment. The emergence of pediatric cases of multisystem inflammatory syndrome related to the SARS-CoV-2 infection (PIM-TS) has raised concerns over the issue of hepatic damage and liver enzyme elevation in the critically ill pediatric population with COVID-19. Some retrospective cohorts and case series have shown various degrees of ALT/AST elevation in SARS-CoV-2 infections. A limited number of liver histopathological studies are available that show focal hepatic periportal necrosis. This liver damage was associated with higher levels of inflammatory markers, C-reactive protein (CRP), and pro-calcitonin. Proposed pathophysiological mechanisms include an uncontrolled exacerbated inflammatory response, drug-induced liver injury, direct viral infection and damage to cholangiocytes, hypoxic-ischemic lesions, and micro-thrombosis in the liver. Based on the physiopathological characteristics described, our group proposes a clinical protocol for the surveillance, evaluation, management, and follow-up of critically ill pediatric COVID-19 patients with liver damage.

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