Hepatobiliary Manifistations of COVID-19 in Sickle Cell Disease: A Case Report
Authors: Alghamdi Badria M. , Kashari Ohoud F. 
Published: November 2020

Hepatobiliary manifestation of COVID-19 in Sickle Cell Disease: A Case report.
Background and aim:
SARS-CoV-2 belongs to the Coronaviridae family, and the virus began spreading worldwide in late December 2019. It mainly affects the respiratory system. However, some studies have shown an increasing number of patients reporting gastrointestinal manifestations associated with COVID-19. There is little clinical experience of COVID-19 patients with sickle cell disease (SCD) especially in our country, and most reported cases presented with acute chest syndrome (ACS). Sickle cell hepatopathy is common and ranges from benign hyperbilirubinemia and biliary sludge to overt liver failure, but it is unclear how this is affected by COVID-19.
Case presentation:
We report a case of a 5-year-old Saudi, non-obese female who was diagnosed as sickle B+ thalassemia (HbS: 71.9%, HbA 1.4%, HbA2: 6 & HbF: 20.7%) and was on hydroxyurea, folic acid, and vitamin D. The child came to our Emergency Department on 28/7/2020 with a one-week history of generalized abdominal pain related to the food ingestion and associated with vomiting and diarrhea. There is a history of jaundice, dark urine, and clay-like stool. There was no documented fever, history of cough, or respiratory distress. There was a history of contact with Covid-19 patient. On clinical examination, the child was vitally stable but jaundiced. She was in pain with tenderness over the right part of the abdomen but no organomegaly; other systematic examinations were normal. Her initial laboratory finding showed elevated liver enzyme (ALT: 148U/L, AST: 89U/L, GGT:150U/L, ALP:149U/L) with direct hyperbilirubinemia (total bilirubin 4.5mg/dl and direct bilirubin 2.6 mg/dl), high reticulocyte, and stable hemoglobin (10 mg/dl). She had a normal leukocyte count, platelet count, inflammatory markers, and pancreatic enzymes. Her abdominal U/S showed no hepatic focal lesions detected with normal size liver and no evidence of intrahepatic bile duct dilatation. In addition, the common bile duct and the portal vein were not dilated. The gallbladder showed normal wall thickening and was partially filled with sludge without stones (Figure 1).
The child was kept on diet restriction and treated with maintenance intravenous fluid (IVF) and paracetamol. Hydroxyurea was stopped. Her gastrointestinal manifestations improved, and the liver enzymes subsided within days (Figure 2). After four days, the child was discharged home. Two days later, she was readmitted with poor oral intake and generalized upper limb pain (vaso-occlusive crisis). There was no clinical finding on examination. Her laboratory finding was acceptable, and she was started on IVF and analgesia. On 8/8/2020, she was discharged in very good clinical condition.
Conclusions:
It is clear that COVID-19 has significant impact on SCD. Poor oral intake that associated with viral infection can cause biliary sludge and Close follow-up is essential for those patients. Further studies are needed to support this finding.

Disclosures
No relevant conflicts of interest to declare.