Age: 39.0
Sex: F
Vaccine: COVID19
Symptoms: Prurigo, Rash, Rash maculo-papular, SARS-CoV-2 test negative, Smooth muscle antibody negative
Clinical narrative: The patient was admitted to the hospital on February 10, 2021 for evaluation of jaundice.  This is a healthcare worker (direct patient care) and she received the first dose of Covid 19 vaccine in January 13 2021, then subsequently developed some abnormalities of the liver enzymes and thrombocytopenia.  Because of this, her second vaccine was held.  She also subsequently noticed scleral jaundice.   She reports that it was 5 days since the COVID-19 vaccine on January 13 when she developed a rash which was present in the legs anterior abdomen and arms.  Then 8 days after the vaccine, she developed a different rash on top of the original which was less petechial and more maculopapular.   The rash is pruriginous, its been intermittently worsening and improving.   She had no fever associated with the rash, although she reports that the day before admission February 9, she had some chills and sweats. She had some mild abdominal pain and cramps.  No prior history of hepatitis.  She also developed a petechial rash predominantly in the lower extremities.  Results of ancillary studies showed that her AST is currently (02/12/21) 196 ALT of 61, her bilirubin total was 7.9 with a direct of 5.5, and on admission her AST was 183 ALT 40, with a total bilirubin of 14.  Her platelet count on admission was 111, currently is 93.  She has some mild microcytic anemia and no leukopenia and in the differential she has increased monocytosis.  Her viral hepatitis serology panel shows hepatitis a IgM that is negative hepatitis B surface antigen and core antibody negative, hepatitis B surface antibody positive consistent with previous vaccination, and hepatitis C antibody negative. COVID-19 antigen was negative on admission 2/10/2021 she reports that she had a Covid PCR done in her office 5 days or so before admission that was also negative. She has been seen by our GI who evaluated her liver abnormalities.  Imaging studies including a CT scan of 2/10/2021 showed chronic changes in the colon that could be consistent with inflammatory process such as ulcerative colitis, and a diffuse heterogeneous enhancement of the liver with nodularity that could be consistent with cirrhosis.  She has a splenic varices and gastric varices which would make the diagnosis of cirrhosis certainly possible.  An MRI of her abdomen on 2/11/2021 shows confirmation of the cirrhotic changes in the liver biliary dilatation or gallbladder abnormalities.  There is evidence of portal hypertension. He also had a liver ultrasound that shows findings consistent with possible cirrhosis, including splenomegaly, hepatomegaly, and GB sludge. Alpha 1 antitrypsin, LKM antimitochondrial and anti-smooth muscle antibodies are negative.  ANA and ANCA are pending.  CMV and EBV PCR are pending. Given the unclear underlying etiology of her liver abnormalities, she had a liver biopsy. Result-Suggestive of NASH and confirms F4 cirrhosis. The patient was a started on Cipro and Flagyl empirically because of the findings on the colon suggestive of possible cholangitis.  She has normal renal function.  She has had no tick bites, no exposure to animals, no external factors consistent with atopic dermatitis or allergic type of rash.    She reports that before admission, she had normal platelets about 1 or 2 years ago when she was tested, as well as normal liver function test.  She reports that she has had some mild epistaxis as well as bleeding from her lips.  She has some anorexia, she has had some looser stools but has been clear without obvious blood and she has had no hematuria. EGD on 15FEB2021- mild portal hypertensive gastropathy. Low risk esophageal varices. Labwork 15FEB2021- AST 173/ALT 64/Alk Phos 235/Plt 109/ Discharged on 02/15/2021 to home with plans for follow-up with GI and PCP.  Prescribed Prednisone with taper off after 28 days. Follow-up appointment has not yet occurred as of the day this report is submitted(2/19/2021).