Age: 49.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Hypertransaminasaemia, Intensive care, International normalised ratio increased, Ischaemic hepatitis, Laboratory test
Clinical narrative: 50M presented 8/17/22 with hx sarcoidosis, NICM/HFrEF s/p ICD, AF, CKD5, current smoking came to the EC 8/17 with fever and intractable nausea/NBNB vomiting/watery NB diarrhea. He tested COVID positive 2 days prior and is vaccinated against COVID x3 with this being his first COVID infection. He denied respiratory complaints. In the EC he was AFVSNL and examination noted scleral icterus. Labs revealed only mildly elevated PT/INR but AST 6520, ALT 2444, T bili 1.7, BUN/Cr 91/6.2, and hyperkalemia 5.8. MICU and GI were consulted and further imaging and labs were ordered with consideration for transaminitis secondary to shock, viral hepatitis, congestion, drug-induced etiologies. Ultimately he was admitted to Facility acute COVID infection c/b significant transaminitis in the thousands, rhabdomyolysis, AKI on CKD5, and hyperkalemia 5.8. His acetaminophen and EtOH levels were undetectable and he was not hypotensive though tachycardic on presentation. He had normal hepatic morphology on MRI abdomen 2022. GI's current leading diagnosis is acute viral hepatitis with transaminitis compounded by rhabdomyolysis versus shock liver versus AI liver disease versus vascular pathology. GI recommended BCx, viral serologies, ANA/ASMA/AMA/LKM/ceruloplasmin, empiric IV NAC, hydration for rhabdo, doppler US to r/o vascular pathology, echo, tending LFT's/PT/INR/daily MELD labs, neurochecks. His acetaminophen and EtOH levels were undetectable and he was not hypotensive though tachycardic on presentation. He had normal hepatic morphology on MRI abdomen 2022. GI's current leading diagnosis is acute viral hepatitis with transaminitis compounded by rhabdomyolysis versus shock liver versus AI liver disease versus vascular pathology. GI recommended BCx, viral serologies, ANA/ASMA/AMA/LKM/ceruloplasmin, empiric IV NAC, hydration for rhabdo, doppler US to r/o vascular pathology, echo, tending LFT's/PT/INR/daily MELD labs, neurochecks. Nephrology consulted for AKI on CKD5 and rhabdomyolysis c/b hyperkalemia, hyperphosphatemia, hypocalcemia. Cardiology consulted for NSTEMI with troponin 0.51 and ST-T abnormalities. He had elevated d-dimer 9753 with thrombocytopenia 121. His home bumex and metoprolol were held while hydralazine continued and coreg initiated given his HFrEF. He was noted to have chronic anemia around Hb 9-11 for which outpatient iron studies should be considered. ID was consulted given his COVID infection: Paxlovid precluded by CrCl <30, remdesivir not recd 2/2 transaminitis, no currently available mAb, ideally vax prevent declining resp disease in this setting; liver damage could be COVID, consider hypovolemia/hypotension; consider babesiosis, ehrlichiosis, anaplasmosis, RMSF; check parasite smears and RMSF serology, started doxy 100 mg IV q12 8/18.His CK was ~4500 and declined on repeat. For electrolyte abnormalities in context of his CKD5 he was continued on Renvela 800 mg TID. He was discharged in stable condition with renal function at baseline, acidosis significantly improved, liver function tests down-trending, and appetite adequate without further nausea/vomiting/diarrhea.