bs_bs_banner doi:10.1111/jgh.15537 E D U C AT I O N A N D I M A G I N G We report a patient who presented intrahepatic cholangitis and cholecystitis after SARS-CoV-2 infection Table 1 Evolution of analytical parameters. Bilirubin AST ALT ALP GGT Platelet count CRP IL-6 9 (μmol/L) (U/L) (U/L) (U/L) (U/L) (x10 /L) (mg/L) (pg/mL) Jun 13 48 100 358 196 322 261 12.5 - Jun 26 35 156 214 648 1166 425 56.7 34.2 Jul 6 35 152 242 1175 1439 423 41.4 22.0 Jul 27 21 125 162 615 645 296 4.1 - Oct 20 11 35 48 151 226 272 <1 - AST: aspartate aminotransferase; ALT: alanine aminotransferase; ALP: alkaline phosphatase; GGT: gamma-glutamyl transferase, CRP: C-reactive protein. A 24-year old woman was hospitalized on June 13 2020 for fever (38 C°), right upper abdominal pain, pruritus, and a skin rash of Figure 1 a) MRI showing normal biliary tree (red arrows) and wall one week’s duration. Two months earlier she had had fever (38.5 edema of the gallbladder (white arrows); b) desquamation of palms C°), malaise and cough that resolved in one week without medical and finger peeling; c) liver biopsy revealed cholangitis of the small bile attention. ducts consisting of a mixed inflammatory infiltrate with lymphocytes, Physical examination showed a diffuse macular erythematous plasma cells and neutrophils (black arrows) accompanied by eosinophils monomorphic rash on trunk and limbs and right upper quadrant (white arrow) localized around and within the bile ducts; d) cholecystec- abdominal tenderness. Analysis showed lymphopenia, alterations tomy specimen showed subacute and chronic acalculous cholecystitis in liver function tests and a mild increase in C-reactive protein with eosinophils, vascular ectasia, and formation of occasional and IL-6 (Table 1). Urine sediment, blood cultures and chest endoluminal thrombus (black arrow). X-ray were normal. Nasopharyngeal exudate was positive for SARS-CoV-2 PCR and antibodies were positive for IgG and negative for IgM. Abdominal ultrasound and biliary MRI showed direct viral effect, to the proinflammatory state, or to drugs used thickening of the gallbladder wall without lithiasis or bile duct for treatment. However, severe intrahepatic cholangitis and dilatation (Figure 1a). cholecystitis has not been previously reported. The angiotensin- Intravenous antibiotic treatment with ceftriaxone and metroni- converting enzyme 2 receptor and the transmembrane protease dazole was started but fever, abdominal pain and rash persisted. serine subtype 2 are responsible for SARS-CoV-2 cell tropism Cracked lips, desquamation of palms and soles and finger peeling and are expressed in the liver, mainly in cholangiocytes. In the appeared (Figure 1b). On June 23 a laparoscopic cholecystectomy present case, a direct effect of the virus on cholangiocytes is and liver biopsy were performed. The pathology is shown in unlikely considering the serological profile and the time lapse Figure 1c and Figure 1d. between possible SARS-CoV-2 infection and the clinical picture. After surgery, fever (<38C°), anorexia, abdominal pain and In view of the patient’s age, the concomitant presence of skin rash, finger peeling persisted. Liver function tests were higher than cracked lips, finger peeling, thrombocytosis and the proinflamma- before surgery and platelet count had increased (Table 1). Further tory state we considered the patient could have had a multi-system analysis ruled out viral, parasitic, metabolic, and autoimmune inflammatory syndrome mimicking an incomplete Kawasaki etiology, including IgG4 levels. On this point, cholangitis in the disease induced by SARS-CoV-2, a phenomenon mainly reported context of a multi-system inflammatory syndrome mimicking an in children. In effect, intrahepatic cholangitis and hydrops of the incomplete adult Kawasaki disease was suspected and treatment gallbladder have been described in association with Kawasaki with ursodeoxycholic acid and aspirin was initiated. A cardiac disease not related to SARS-CoV-2. CT scan ruled out coronary aneurisms. Immunoglobulin treatment was not initiated due to the lack of a marked inflammatory state at Contributed by diagnosis and the already increased thrombotic risk due to J Fajardo,* E Núñez,* J Szafranska,† M Poca,* D Lobo,‡ coronavirus disease-19 (COVID-19). Her subsequent evolution B Martín,§ D Hernández,¶ C Roig,* A Huerta,* H Corominas,‡ was satisfactory with progressive resolution of symptoms and S Sánchez-Cabús§ and G Soriano *,** improvement of liver function tests. Alterations in liver tests in patients with COVID-19 are usually Departments of *Gastroenterology, †Pathology, ‡Rheumatology, § mild and transient. They predominantly show an increase in Surgery, ¶Radiology, Hospital de la Santa Creu i Sant Pau, transaminases, and are more often seen in patients with a severe Autonomous University of Barcelona, Barcelona, and clinical course. Such alterations are considered secondary to a **CIBERehd, Instituto de Salud Carlos III, Madrid, Spain Journal of Gastroenterology and Hepatology (2021) ••–•• 1 © 2021 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd