key: cord-0754605-prlyrjgm
authors: Zhang, Bin; Huang, Wenhui; Zhang, Shuixing
title: Clinical Features and Outcomes of Coronavirus Disease 2019 (COVID-19) Patients With Chronic Hepatitis B Virus Infection
date: 2020-06-15
journal: Clin Gastroenterol Hepatol
DOI: 10.1016/j.cgh.2020.06.011
sha: 8abc183d6c8df182071b5f04e476700a33c02897
doc_id: 754605
cord_uid: prlyrjgm

nan

Dear Editor:

We read with great interest the recent article published in Clinical Gastroenterology and Hepatology by Fan et al, 1 in which they described the characteristics of coronavirus disease 2019 (COVID-19)-related liver damage. Since the outbreak of COVID-19, liver injury has attracted widespread attention, which might be caused by pre-existing liver disease, virus infection of liver cells, and certain medications. The effect of virus infection and antiviral drugs on liver injury has been considered, however, the report and diagnosis on chronic liver disease is insufficient in this emergent situation. In a recent large cohort study, only 1.3% of COVID-19 patients recorded a history of chronic viral hepatitis, 2 which was significantly lower than the population prevalence in China. 3 Patients with pre-existing liver disease are a high-risk population for COVID-19. In this study, we aimed to report the clinical course of COVID-19 patients with chronic hepatitis B virus (HBV) infection and provide a reference for clinical treatment of patients.

From January 24, 2020, to February 29, 2020, patients with confirmed COVID-19 and chronic HBV infection were admitted to 2 designated hospitals for COVID-19. COVID-19 was confirmed by the detection of severe acute respiratory syndrome coronavirus 2 RNA in throat swabs by reverse-transcription polymerase chain reaction. Patients with abnormal liver enzyme levels at admission or a history of chronic liver diseases might undergo HBV assays. HBV infection was defined by a positive test result for hepatitis B surface antigen. HBVinfected patients are classified as hepatitis B virus carriers, chronic hepatitis B, and hepatitis B cirrhosis. 4 We defined liver injury as any parameter exceeding the upper limit of normal value of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL). 5 The definition of severity degree and the clinical management of COVID-19 patients were in accordance with the practice guidelines issued by China. 6 This study was approved by ethics commissions, and written informed consent was waived.

All of the patients in this study had a COVID-19 exposure history. Of the 23 patients, the mean age was 44.7 AE 11.5 years, and 15 (65.2%) were male. Only 6 (26.1%) patients reported a history of being a HBV carrier, 4 (17.4%) patients reported a history of chronic hepatitis B, but the remaining patients (56.5%) denied a history of HBV infection. The patients reported no other underlying diseases. However, laboratory tests at admission showed that 15 patients were HBV carriers, 7 (30.4%) had chronic hepatitis B, and 1 (4.4%) had hepatitis B cirrhosis. At admission, 6 (26.0%) patients had liver test result abnormalities, of which 2 patients were HBV carriers, 3 patients had chronic hepatitis B, and 1 patient had hepatitis B cirrhosis. Ten patients had increased liver enzyme levels during hospitalization, with AST, ALT, and TBIL ranges of 44 to 277 U/L, 52 to 575.1 U/L, and 17.5 to 309.18 mmol/L, respectively. All patients were mild/ moderate on admission, but 3 (13.0%) patients progressed to severe, and 2 (8.7%) progressed to critically ill. The 23 patients were treated with antiviral drugs and 13 were treated with liver-protecting drugs. After treatment, all patients were discharged. The comparison of HBV carriers and patients with chronic hepatitis B/hepatitis B cirrhosis is shown in Table 1 . The results showed no significant differences in all clinical features except for sex, exposure history, activated partial thromboplastin time, AST, ALT, g-glutamyl transpeptidase (GGT), TBIL, and direct bilirubin. Notably, no differences were found in disease severity or length of hospital stay between these 2 groups. The 5 severe/critically ill patients (cases A-E) all were male. These 5 patients were admitted to the intensive care unit, 3 required noninvasive mechanical ventilation and all were treated with corticosteroids. During intensive care unit treatment, case A developed deep venous thrombosis, cases B and C developed acute respiratory distress syndrome, and case D developed upper gastrointestinal hemorrhage, liver failure, and renal insufficiency. Figure 1 shows follow-up liver function tests of the 5 patients during hospitalization. The increase in ALT level was significantly higher than AST. The ALT increase is the primary indicator of liver injury in COVID-19. 7, 8 The GGT increase was not significant. Before discharge, liver function of the 5 patients could not return to baseline. Because of the emergence of COVID-19, the report and diagnosis on chronic HBV infection is insufficient, therefore, the impact of HBV infection on liver injury might be underestimated. Most HBV carriers with COVID-19 will not progress to becoming severely or critically ill. However, 26% of patients had abnormal liver function test results at admission, 19% of whom progressed to being severely or critically ill, which was not associated with HBV infection status. Accordingly, we recommend dynamic monitoring of liver function in COVID-19 patients with liver test abnormalities at admission. ALT and AST levels, especially ALT levels, are preferred parameters that should be used to monitor liver function during hospitalization.

BIN ZHANG, PhD a WENHUI HUANG, PhD a SHUIXING ZHANG, MD, PhD The First Affiliated Hospital of Jinan University Guangzhou, Guangdong, China

Epub ahead of print

Epub ahead of print

State Administration of Traditional Chinese Medicine. Diagnosis and treatment protocol for novel coronavirus pneumonia

The authors thank all the medical workers for fighting against COVID-19, and to the people of the country and the world for their contributions to this campaign.

The authors disclose no conflicts.

https://doi.org/10.1016/j.cgh.2020.06.011

COVID-19 and Inflammatory Bowel Disease: Questions on Incidence, Severity, and Impact of Treatment?Dear Editor:Since the emergence of coronavirus disease 2019 (COVID-19) (severe acute respiratory syndrome-associated coronavirus 2 [SARS-CoV-2]) infection in December 2019, numerous questions arise on the specific risk of COVID-19 in patients with inflammatory bowel disease (IBD), in particular those treated by immunosuppressants and/or biologics.In a large cohort of IBD patients from Nancy University Hospital (France) and Humanitas (Milan, Italy), Allocca et al 1 reported 15 COVID-19-positive patients (9 Crohn's disease [CD] patients, 3 with active disease, 14 with immunosuppressants and/or biologics), representing a cumulative incidence of 0.0025; all had a favorable outcome (only 5 were hospitalized, not requiring intensive care support). During the same period, we identified 7 patients with proven infection. Four were male, median age was 54 years (34-60), 5 had CD, 5 had inactive disease, and 4 had comorbidities (obesity in 4, hypertension in 1, chronic pulmonary obstructive disease in 1). Diagnosis was based on polymerase chain reaction nasopharyngeal swab testing in 4 and enzyme-linked immunosorbent assay in 3. One patient was asymptomatic. Two needed short-term hospitalization without intensive care support. Two patients were on combination therapy (ustekinumab/azathioprine and vedolizumab/methotrexate), 1 had ustekinumab and 20 mg a day prednisolone for CD flare-up, 2 had anti-tumor necrosis factors (TNFs) (1 infliximab, 1 adalimumab), 1 had tofacitinib (10 mg twice a day), and 1 was on no treatment. Taken together, these results are reassuring for IBD patients and their treating physicians.However, IBD patients with COVID-19 can have negative outcomes. Bezzio et al 2 reported endotracheal intubation in 8% and death in 8% of 79 COVID-19-infected IBD patients. Negative outcome was associated with age older than 65, comorbidities, and active disease. 2 The association with older age and comorbidities has also been reported in the international IOIBD SECURE registry (http://www.covidibd.org). 3, 4 In describing the characteristics and outcomes of the first 525 cases in IOIBD SECURE registry, older age and having !2 comorbidities were positively associated with COVID-19 severity. 3 Systemic corticosteroids or mesalamine increased the risk of severe infection (adjusted odds ratio, 6.9; 95% confidence interval [CI], 2.3-20.5, and 3.1; 95% CI, 1.3-7.7, respectively), whereas anti-TNFs were not associated with worse outcome. 3 These results seem to persist (although with no statistical analysis yet) in the updated data from the IOIBD SECURE registry, showing that among 1170 reported IBD patients with COVID-19 infection, 4% had died, with a clear increase in patients older than 60 and/or having !2 comorbidities. 4 The difference in risk of severe infection and/or death related to treatment is more difficult to analyze with these raw data. 5 In fact, it would be of outstanding interest to have data from whole IBD patients' cohort(s) including both infected and noninfected patients to better outline the protective (or harmful) effect of the different treatments after adjusting for the other known risk factors. 6