S5879 Significantly Elevated Transaminases in a Patient With Norovirus Infection

Introduction: Norovirus is a leading cause of food borne illness in the United States and causes symptoms of abdominal pain, vomiting, and diarrhea. In immunocompetent patients, norovirus is characteristically acute and self-limiting. We present an unusual case of norovirus gastroenteritis leading to markedly elevated transaminases, a connection that has seldom been reported in the literature. Case Description/Methods: A 24-year-old man with no significant past medical history presented with abdominal pain, vomiting, and jaundice one day after eating pork at a social event. He denied drug and alcohol use. He did not take any medications or supplements. Physical exam revealed jaundice and epigastric tenderness. Initial labs revealed an aspartate aminotransferase (AST) of 1205, alanine aminotransferase (ALT) of 2,170, alkaline phosphatase of 197, total bilirubin of 6.1, direct bilirubin of 4.43, international normalized ratio of 1.4, and albumin of 3.8. Hepatitis panel, acetaminophen level, alcohol level, urine drug screen, lipase, LKM-1, ceruloplasmin, AMA, ANA, ASMA, dsDNA, ferritin, IgG levels, EBV, CMV, and HSV were unremarkable. GI panel revealed a positive norovirus result. Gastroenterology was consulted, and recommended N-acetylcysteine for empiric management of the acute liver injury. Abdominal ultrasound and Computed tomography showed no acute process. MRCP showed findings consistent with acute hepatitis, mild splenomegaly, and mildly enlarged portal vein. Although the patient's symptoms resolved a few days into his hospitalization, his hepatic function testing worsened. Labs revealed a peak AST of 2597, ALT of 3541, total bilirubin of 34.1, and international normalized ratio of 2.2. This prompted the pursuit of a liver biopsy, which revealed acute liver injury favoring alcohol-related acute hepatitis. However, a PEth level obtained during hospitalization was negative. Thus, the patient's acute liver injury was attributed to norovirus. He was treated with corticosteroids with eventual improvement in his liver enzymes and discharged on day 19 of hospitalization. Labs done one month later showed improving AST and ALT levels of 92 and 149, respectively. Bilirubin levels improved to a level of 3.8. Discussion: This case highlights a rare association between acute liver dysfunction and norovirus gastroenteritis. To our knowledge, this is the first case report demonstrating a rise of this magnitude with regard to AST and ALT levels in a patient with norovirus infection. Although this association is rare, clinicians should consider acute liver injury as a possible extra-intestinal manifestation of norovirus infection.