Liver Histopathology of Deceased Patients with COVID-19: A Case Series from Tehran, Iran

Background: SARS-CoV-2 receptors are distributed in several vital organs, and many of these organs are damaged in severe COVID-19. Liver inflammation in COVID-19 ranges from asymptomatic elevation of liver transaminase levels to fulminant hepatitis. Objectives: The present study aimed to investigate the liver histopathology of deceased patients with COVID-19. Methods: This case series study was conducted in Tehran, Iran, in 2021. The subjects were deceased patients with COVID-19. After obtaining informed consent from the first-degree relatives, at least two liver tissue samples were obtained through the right 10th to 12th intercostal spaces using a biopsy needle, following the Helsinki biopsy guidelines. Clinical information from the patients was extracted using a questionnaire. Fisher's exact test and Student’s t-test were used to analyze the data. Results: Liver sampling was performed in 12 deceased patients. The mean age of the patients was 73 years, with a male-to-female ratio of 9:3. The most common clinical cause of death was adult respiratory distress syndrome (ARDS), occurring in eight patients. An increase in liver transaminase levels was observed in four patients. Histopathological examination revealed normal results in three patients, moderate to severe inflammation according to the [non-alcoholic fatty liver disease (NAFLD) activity score (NAS score)] in eight patients, and mild NAS scores in four patients. Liver inflammation was not correlated with other parameters, including sex, diabetes mellitus (DM), chronic renal failure (CRF), transaminase level, Body Mass Index (BMI), C-reactive protein (CRP) level, or length of stay in hospital. Liver steatosis was observed in four of the 12 patients and was significantly associated with a higher BMI (P = 0.014). Conclusions: In our study, most patients exhibited a moderate-to-severe NAS score that did not correlate with disease severity or underlying medical conditions. We recommend regular assessment of clinical and biochemical indicators of liver inflammation in individuals with severe COVID-19.