COVID-19 Infection Presenting as an Isolated Severe Acute Liver Failure

The clinical features of severe acute respiratory syndrome-coronavirus disease 2019 (SARS-COVID-19) infection range from mild upper respiratory symptoms to severe acute respiratory failure. Among other less common features are diarrhea, nausea, vomiting, elevated liver enzymes, and acute kidney injury. We present a case of a 49-year-old female with no preexisting liver disease who presented with weakness and dizziness for one week. Initial investigations revealed acute liver failure (ALF) and positive COVID-19 on polymerase chain reaction (PCR) testing. The patient did not have any upper or lower respiratory symptoms, and extensive workup to look for other etiologies of acute liver failure was unremarkable. She eventually deteriorated to decompensated liver failure and was transitioned to comfort measures only. Liver injury is a well-documented phenomenon associated with COVID-19 infection. Some of the common pathophysiological mechanisms include direct liver injury, immune-mediated liver damage due to the severe inflammatory response, ischemic injury, endothelial disruption, and coagulopathy. Our case uniquely highlights that SARS-COVID-19 infection may have the potential to solely affect hepatocytes without the classic severe acute respiratory distress syndrome. This case demonstrates that a diagnosis of COVID-19 may be considered if no other etiology of ALF is identified.