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Findings of Severe Hepatic SARS-CoV-2 Infection

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Background and Aims

Liver injury due to COVID-19 is being increasingly recognized. Abnormal liver chemistry tests of varying severities occur in a majority of patients. However, there is a dearth of accompanying liver histologic studies in these patients. Methods: The current report details the clinical courses of two patients having severe COVID-19 hepatitis. Liver biopsies were analyzed under light microscopy, portions of liver tissue were hybridized with a target probe to the SARS-CoV-2 S gene, and small sections from formalin-fixed paraffin embedded liver tissue were processed for electron microscopy.


The liver histology of both cases showed a mixed inflammatory infiltrate with prominent bile duct damage, endotheliitis and many apoptotic bodies. In-situ hybridization and electron microscopy suggest the intrahepatic presence of the severe acute respiratory syndrome corona virus-2 (SARS-CoV-2), the findings of which may indicate the possibility of direct cell injury.


Based on the abundant apoptosis and severe cholangiocyte injury, these histopathological changes suggest a direct cytopathic injury. Furthermore, some of the histopathological changes may resemble acute cellular rejection occurring after liver transplantation. These two cases demonstrate that severe COVID-19 hepatitis can occur even in the absence of significant involvement of other organs.

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Conflict Of Interest: The authors have no conflict of interest.

Author contributions to manuscript:

Fiel – diagnosis, histology interpretation, concept, writing,

El Jamal – diagnosis by in-situ hybridization, writing

Paniz-Mondolfi – electron microscopy images interpretation, writing

Gordon – electron microscopy

Reidy – electron microscopy

Bandovic – histology and diagnosis

Advani – clinical history

Kilaru – clinical history

Pourmand – clinical care

Ward – histology interpretation

Thung – histology interpretation

Schiano – concept, writing of manuscript


DOI: https://doi.org/10.1016/j.jcmgh.2020.09.015


© 2020 The Authors. Published by Elsevier Inc. on behalf of the AGA Institute.

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