An 11-Year-Old Boy Infected with COVID-19 with Presentation of Acute Liver Failure


avatar Amir Saeed ORCID 1 , avatar Eslam Shorafa 1 , avatar Iraj Shahramian ORCID 2 , * , avatar Mahdi Afshari 2 , avatar Mehrdad Salahifard 2 , avatar Fateme Parooie 2

Division of Pediatric Intensive Care Unit, Department of Pediatrics, Shiraz University of Medical Science, Shiraz, Iran
Pediatric Gastroenterology and Hepatology Research Center, Zabol University of Medical Sciences, Zabol, Iran

how to cite: Saeed A, Shorafa E, Shahramian I, Afshari M, Salahifard M , et al. An 11-Year-Old Boy Infected with COVID-19 with Presentation of Acute Liver Failure. Hepat Mon.20(6):e104415. doi: 10.5812/hepatmon.104415.


Coronavirus disease 2019 (COVID-19) first emerged in Wuhan, China, in December 2019. Then, it spread to the whole world so that THE World Health Organization (WHO) declared a worldwide pandemic on March 11, 2020. Coronavirus disease 2019 is a novel and mysterious infectious disease that causes respiratory illness, multiorgan failure (MOF), and death. Although pediatric COVID-19 accounts for a small percentage of patients and is often milder than in adults, it can progress to severe disease in some cases. Liver involvement in COVID-19 and its severity have not been clearly investigated. In this paper, we present an 11-year-old boy admitted to a Pediatric Intensive Care Unit (PICU) with COVID-19 diagnosis in combination with elevated liver enzymes and bilirubin.

1. Introduction

In January 2020, a sample collected from Bronchoalveolar lavage fluid of a patient in Wuhan showed the 2019 novel coronavirus (2019-nCoV) and it was confirmed as the cause of a cluster of acute respiratory illnesses in Wuhan, China (1). The virus was named SARS-CoV-2 (severe acute coronavirus 2), and the disease was defined as coronavirus disease 2019 (COVID-19) (2, 3). On February 11, the World Health Organization (WHO) announced COVID-19 as a pandemic. In February 2020, the first infected people were detected in Qom City in Iran, and then the disease spread to other cities over the country. The first pediatric case was reported on January 20, 2020, in a 10-year old boy in China (4). There are limited data on the prevalence of COVID-19 in the pediatric population in China, as children were rarely tested for the virus in the earlier phase of the outbreak, especially in Hubei Province, China, with the highest number of confirmed patients (5).

Coronavirus disease 2019 seems to infect children less than adults, with milder manifestations (6). The common signs and symptoms of COVID19 include fever, cough, rhinorrhea, diarrhea, myalgia, nasal congestion, sore throat, headache, dizziness, nausea, vomiting, abdominal pain, diarrhea, and fatigue, the most common of which are fever and cough. Previously, we had the epidemics of two beta coronaviruses, namely severe acute respiratory syndrome coronavirus (SARS-CoV) (7, 8) and the Middle East respiratory syndrome coronavirus (MERS-CoV) (9, 10), and COVID-19 is the third one. Some studies have shown that patients with SARS-CoV or MERS had liver injuries with elevated liver enzyme and bilirubin levels, which were mainly in mild degrees (10-13). Studies of COVID-19 infection have shown that the incidence of liver injury ranges from 14.8% to 53%, mainly presenting with abnormal alanine transaminase/aspartate aminotransferase (ALT/AST) levels accompanied by slightly elevated serum bilirubin. However, the serum level of alkaline phosphatase (AKP) remains in the normal range in both mild and severe cases (14, 15). The decreased level of albumin can be identified in severe cases ranging between 26.3 and 30.9 g/L. Liver injury was significantly higher in severe COVID-19 patients than in mild cases (16). In the deceased cases of COVID-19, the incidence of liver injury might reach up to 78%. One study reported that serum ALT and AST levels increased up to 7,590 U/L and 1,445 U/L, respectively, in a severe COVID-19 patient (15). According to evidence, the hepatic injury may occur among adult COVID-19 patients. However, there are limited data regarding liver involvement among critical pediatric patients admitted to the PICU.

2. Case Presentation

An 11-year- old boy presented with fever and abdominal pain without improvement after an outpatient visit by a family physician. The past medical history was unremarkable. His condition got worse after two days with the increased respiratory rate; thus, he was referred to the hospital and admitted to the pediatric ward. Despite medications during hospitalization, the fever did not subside and he developed yellowish discoloration of the skin and decreased level of consciousness. Therefore, he was transferred to Namazi Hospital, Shiraz, Iran, with the impression of acute liver failure for liver transplantation (after seven days of symptoms onset). His vital signs when arriving in the emergency room were blood pressure 90/45, heart rate 135, respiratory rate 58, and Glasgow Coma scale (GCS) 6/15. In a physical exam, he had weak pulses. He was intubated and transferred to the PICU. An interview with his parents showed that they both had fever and cough with the history of travel to Babol, North of Iran (one of the first COVID-19 epidemic zones in Iran). According to the findings of chest CT scan (bilateral ground glass) (Figure 1), laboratory data, and positive real-time polymerase chain reaction (RT-PCR) of his parents and despite the negative oropharyngeal swab samples of the patient, the routine COVID-19 therapy (hydroxychloroquine plus Kaletra (lopinavir/ritonavir)) started in combination with broad-spectrum antibiotics. It should be noted that the second specimen for COVID-19 was positive. His laboratory data in the PICU are listed in Table 1. Blood culture at PICU admission was negative, and the ceruloplasmin and ammonia levels were in the normal range. However, his condition was deteriorated due to refractory hypotension and decreased urine output. After PICU admission, he suddenly experienced an atrial fibrillation (AF) and asystole without response to cardiopulmonary resuscitation (CPR) and expired.

Table 1. Laboratory Data of the Patient
Laboratory VariableVariable LevelReference Interval
White blood cells, count/mL69004000 - 11000
C-reactive protein, mg/L150< 6
Blood urea nitrogen, mg/L1008 - 20
Aspartate transaminase, U/L2030M: < 37; F: < 31
Alanine aminotransferase, U/L690F: < 31; M: < 41
Alkaline phosphatase387-
Total bilirubin35.40.1 - 1.2
Direct bilirubin21.6< 0.3
LKM Ab2< 18
Lactate dehydrogenase, U/L5660< 480
Troponin, ng/mL3343< 19
D.dimer, ng/mL10000< 500
PaO2-FIO2 ratio200-
Procalcitonin10.1≤ 0.3
Partial trombone time15.9-
International normalized ratio (INR)1.3-

3. Discussion

Coronavirus disease 2019 is a novel infectious disease caused by SARS-CoV-2. In December 2019, pneumonia cases of unknown origin were first identified in Wuhan, China, and then rapidly spread to the whole country. Up to date, most countries worldwide have been affected. Our case was an 11-year-old boy infected with COVID-19 that presented with acute hepatitis. His EBV/CMV tests were negative and his parents were positive for COVID-19. The patient had a negative test for COVID-19, followed by a positive result. Generally, the mortality rate of COVID-19 in children is very low, and this case is the first presentation of such degree of severity with acute hepatitis. We assessed viral hepatitis serology, hepatic auto-antibodies, 24 h urine, ceruloplasmin, and copper level to rule out other differential diagnoses. Mild cases of COVID-19 show symptoms of fever, fatigue, dry cough, vomiting, and diarrhea. In severe cases, respiratory distress and/or hypoxemia occur one week after the disease onset, leading to acute respiratory distress syndrome (ARDS), septic shock, metabolic acidosis, and even death (14). Liver damage in patients with COVID-19 infection might be directly induced by a viral infection of liver cells. Approximately, the viral RNA is detected in stool and blood samples of 2% - 10% of the patients (17). The current evidence implicates the possibility of viral infection in the liver. This virus binds to the angiotensin-converting enzyme 2 (ACE2) receptor to enter the target cells (18), where the virus replicates and subsequently infects other cells in the upper respiratory tract and lung tissue. Recent studies of COVID-19 have shown that the possibility of liver injury ranged from 14.8% to 53%, mainly indicated by abnormal ALT/AST levels accompanied by slightly elevated bilirubin levels (14, 15, 18-27). Albumin decreases in severe cases with a range of 26.3 - 30.9 g/L (15). In deceased cases of COVID-19, the incidence of liver injury might reach up to 58.06% (27) to 78% (26). Liver impairment may also be due to drug hepatotoxicity, which might explain the large variation observed across different cohorts. In addition, immune-mediated inflammation, such as cytokine storm and pneumonia-associated hypoxia, might contribute to liver injury or even develop into liver failure in critically ill COVID-19 patients. Bangash et al. (28) study of liver injury of COVID-19 indicated that the post-mortem liver biopsy of a COVID-19 patient showed only micro-vesicular steatosis, which is common in patients with sepsis (28). Fan et al. (21) reported that one in five patients had elevated levels of AST or ALT, which was not so high. Based on these data, they suggested that COVID-19-related liver injury is relatively mild. They also indicated that patients who developed liver damage were more likely to have higher inflammatory indices (C-reactive protein and procalcitonin) and mostly had a fever, which could be related to the immune response to the viral infection (21). Some other studies have found that liver damage is more likely to happen in severe cases of pneumonia, which is suspected to be associated with inflammatory cytokines (14). These results suggest that liver injury can occur among COVID-19 patients. So far, there is insufficient evidence that liver failure occurs in COVID-19 patients with chronic liver disease, such as chronic hepatitis B or C.

3.1. Conclusions

According to the results of the present study, it is proposed to consider COVID-19 infection during any onset of acute hepatitis. In addition, it should be noted that almost all of the previous studies have reported the evidence of hepatic damage only among adults with COVID-19 infection. In contrast, the current study revealed credible evidence regarding the susceptibility of children to liver involvement following this infection.


  • 1.

    Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-33. doi: 10.1056/NEJMoa2001017. [PubMed: 31978945]. [PubMed Central: PMC7092803].

  • 2.

    World Health Organization. Situation report 22. 2020. Available from:

  • 3.

    World Health Organization. Situation report 51. 2020. Available from:

  • 4.

    Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet. 2020;395(10223):514-23. doi: 10.1016/S0140-6736(20)30154-9. [PubMed: 31986261]. [PubMed Central: PMC7159286].

  • 5.

    Cao Q, Chen YC, Chen CL, Chiu CH. SARS-CoV-2 infection in children: Transmission dynamics and clinical characteristics. J Formos Med Assoc. 2020;119(3):670-3. doi: 10.1016/j.jfma.2020.02.009. [PubMed: 32139299]. [PubMed Central: PMC7126646 relevant to this article].

  • 6.

    Society of Pediatrics Chinese Medical Association; Editorial Board Chinese Journal of Pediatrics. [Recommendations for the diagnosis, prevention and control of the 2019 novel coronavirus infection in children (first interim edition)]. Zhonghua Er Ke Za Zhi. 2020;58(0). Chinese. E004. doi: 10.3760/cma.j.issn.0578-1310.2020.0004. [PubMed: 32035429].

  • 7.

    Ksiazek TG, Erdman D, Goldsmith CS, Zaki SR, Peret T, Emery S, et al. A novel coronavirus associated with severe acute respiratory syndrome. N Engl J Med. 2003;348(20):1953-66. doi: 10.1056/NEJMoa030781. [PubMed: 12690092].

  • 8.

    Kuiken T, Fouchier RA, Schutten M, Rimmelzwaan GF, van Amerongen G, van Riel D, et al. Newly discovered coronavirus as the primary cause of severe acute respiratory syndrome. Lancet. 2003;362(9380):263-70. doi: 10.1016/S0140-6736(03)13967-0. [PubMed: 12892955]. [PubMed Central: PMC7112434].

  • 9.

    de Groot RJ, Baker SC, Baric RS, Brown CS, Drosten C, Enjuanes L, et al. Middle East respiratory syndrome coronavirus (MERS-CoV): Announcement of the coronavirus study group. J Virol. 2013;87(14):7790-2. doi: 10.1128/JVI.01244-13. [PubMed: 23678167]. [PubMed Central: PMC3700179].

  • 10.

    Zaki AM, Van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RAM. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med. 2012;367(19):1814-20.

  • 11.

    Zhao LF, Xing HC, Xu LP. [Effect of SARS-associated coronavirus on peripheral blood picture and liver function]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2004;16(11):660-3. Chinese. [PubMed: 15535899].

  • 12.

    Hwang SM, Na BJ, Jung Y, Lim HS, Seo JE, Park SA, et al. Clinical and laboratory findings of middle east respiratory syndrome coronavirus infection. Jpn J Infect Dis. 2019;72(3):160-7. doi: 10.7883/yoken.JJID.2018.187. [PubMed: 30584196].

  • 13.

    Al-Hameed F, Wahla AS, Siddiqui S, Ghabashi A, Al-Shomrani M, Al-Thaqafi A, et al. Characteristics and outcomes of Middle East respiratory syndrome coronavirus patients admitted to an intensive care unit in Jeddah, Saudi Arabia. J Intensive Care Med. 2016;31(5):344-8. doi: 10.1177/0885066615579858. [PubMed: 25862629].

  • 14.

    Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. [PubMed: 31986264]. [PubMed Central: PMC7159299].

  • 15.

    Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet. 2020;395(10223):507-13. doi: 10.1016/S0140-6736(20)30211-7. [PubMed: 32007143]. [PubMed Central: PMC7135076].

  • 16.

    Zhang C, Shi L, Wang FS. Liver injury in COVID-19: Management and challenges. Lancet Gastroenterol Hepatol. 2020;5(5):428-30. doi: 10.1016/S2468-1253(20)30057-1. [PubMed: 32145190]. [PubMed Central: PMC7129165].

  • 17.

    Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: Is faecal–oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol. 2020;5(4):335-7. doi: 10.1016/s2468-1253(20)30048-0.

  • 18.

    Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020. doi: 10.1001/jama.2020.1585. [PubMed: 32031570]. [PubMed Central: PMC7042881].

  • 19.

    Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He X, et al. Clinical characteristics of 2019 novel coronavirus infection in China. medRxiv. 2020. doi: 10.1101/2020.02.06.20020974.

  • 20.

    Cai Q, Huang D, Ou P, Yu H, Zhu Z, Xia Z, et al. COVID-19 in a designated infectious diseases hospital outside Hubei Province, China. Allergy. 2020. doi: 10.1111/all.14309. [PubMed: 32239761].

  • 21.

    Fan Z, Chen L, Li J, Cheng X, Yang J, Tian C, et al. Clinical features of COVID-19-related liver functional abnormality. Clin Gastroenterol Hepatol. 2020;18(7):1561-6. doi: 10.1016/j.cgh.2020.04.002. [PubMed: 32283325]. [PubMed Central: PMC7194865].

  • 22.

    Cao W. Clinical features and laboratory inspection of novel coronavirus pneumonia (COVID-19) in Xiangyang, Hubei. medRxiv. 2020;In Press. doi: 10.1101/2020.02.23.20026963.

  • 23.

    Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: A descriptive study. Lancet Infect Dis. 2020;20(4):425-34. doi: 10.1016/s1473-3099(20)30086-4.

  • 24.

    Xu XW, Wu XX, Jiang XG, Xu KJ, Ying LJ, Ma CL, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: Retrospective case series. BMJ. 2020;368:m606. doi: 10.1136/bmj.m606. [PubMed: 32075786]. [PubMed Central: PMC7224340].

  • 25.

    Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475-81. doi: 10.1016/S2213-2600(20)30079-5. [PubMed: 32105632]. [PubMed Central: PMC7102538].

  • 26.

    Zhang B, Zhou X, Qiu Y, Feng F, Feng J, Jia Y, et al. Clinical characteristics of 82 death cases with COVID-19. medRxiv. 2020;In Press. doi: 10.1101/2020.02.26.20028191.

  • 27.

    Huang Y, Yang R, Xu Y, Gong P. Clinical characteristics of 36 non-survivors with COVID-19 in Wuhan, China. medRxiv. 2020;In Press. doi: 10.1101/2020.02.27.20029009.

  • 28.

    Bangash MN, Patel J, Parekh D. COVID-19 and the liver: Little cause for concern. Lancet Gastroenterol Hepatol. 2020;5(6):529-30. doi: 10.1016/S2468-1253(20)30084-4. [PubMed: 32203680]. [PubMed Central: PMC7270582].

Copyright © 2020, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.