Running Out of Bullets

The Challenging Management of Acute Hepatitis and SARS-COV-2 From the SMatteo COvid19 Registry (SMACORE)

Marta Colaneri; Pietro Valsecchi; Luciano Perotti; Serena Ludovisi; Elena Seminari; Teresa Chiara Pieri; Paolo Sacchi; Raffaele Bruno


Liver International. 2020;40(11):2655-2659. 

In This Article

Abstract and Introduction


Liver impairment is frequent in patients with novel coronavirus disease (COVID-19) and direct viral tropism for the liver has been proven. Since several of the currently administered drugs against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are possibly hepatotoxic, the management of patients with COVID-19 and liver failure is still an almost unexplored field. Taking this challenging case of acute HBV with persistent hyperbilirubinemia and SARS-COV-2 infection with respiratory distress as a starting point, we here loop through this condition. Where the available therapeutic options are scarce, we here propose hemoperfusion (HP) as an attractive alternative to both delay any late-stage progression of hyper inflammation process in COVID-19 and remove the toxins involved in acute liver failure.


Beyond the well-known catastrophic pulmonary effects of coronavirus disease 2019 (COVID-19), the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has also been associated with a significant damage to other organ systems, including kidney, heart, vessels and liver.[1–5] Specifically, the increase in liver enzymes in COVID-19 patients has been reported worldwide[6,7] but the prevalence of liver injury and the associated clinical features of these patients are currently scarce.[8]

Xu et al recently presented a case report of acute on chronic hepatic failure,[9] but no other cases of acute hepatitis occurring during the course of COVID-19 are reported and treatment strategies are currently not well-defined.

Viral hepatitis and COVID-19 is still an almost unexplored field. It is indeed controversial whether patients with chronic Hepatitis B virus (HBV) are likely to have a worse outcome of COVID-19.[10,11] According to Zou et al,[12] patients with SARS-CoV-2 and chronic HBV co-infection with liver injury and coagulation dysfunction were more likely to develop severe illness and had higher mortality.

This selected case of acute HBV hepatitis and COVID-19 is a cue to loop through the challenging coinfection.

We selected the patient case from the SMatteo COvid19 Registry (SMACORE), which is the cohort of patients with a confirmed diagnosis of COVID-19 disease referred to the IRCCS Policlinico San Matteo Hospital of Pavia, Italy, from February 2020.

The SMACORE database includes demographic, clinical laboratory tests, treatment and outcome data. Ethics approval for observational research using SMACORE data was obtained from the local ethics committee.