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Pediatric patients with acute COVID-19 and those with multi-system inflammatory syndrome in children (MIS-C) had evidence of acute liver injury, but each group had different clinical features, a researcher said.

MIS-C patients were younger, had more ICU admissions, and higher levels of inflammatory markers, while COVID-19 patients with acute liver injury were more likely to have higher BMI, reported Amanda Cantor, MD, of Columbia University in New York City.

In fact, BMI was significantly associated with degree of liver injury among kids with COVID-19, but not MIS-C, she said in a presentation at the American Association for the Study of Liver Diseases virtual meeting.

Cantor described how there were "two distinct clinical phenotypes caused by the same virus." She and her colleagues added that MIS-C "changed the perception of the severity of this infection in children," as pediatric manifestations of COVID-19 in children were thought to be mild.

They examined data from 291 patients, ages 21 and younger, at two New York City medical centers from March-May 2020. , but Cantor said these patients had fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization with multi-system organ involvement. Children with COVID-19 had fever, respiratory, and gastrointestinal symptoms. Acute liver injury was categorized as mild if alanine aminotransferase levels were above the upper limit of normal (40-200 U/L), and severe if it was above 200 U/L.

There were 220 patients with acute COVID-19 infection, and 71 with MIS-C. COVID-19 patients with acute liver injury tended to be older (mean age 9) and were more likely to be Hispanic, while MIS-C patients with acute liver injury tended to be older (mean age 13) and were more likely to be boys.

More patients with COVID-19 had a pre-existing condition compared with patients with MIS-C. There was no difference in liver injury between those with COVID-19 who did or did not have a pre-existing condition. If patients with MIS-C had a pre-existing condition, they had a greater likelihood of liver injury, Cantor said.

There was also a difference in inflammatory markers and acute liver injury. As liver injury worsened, this was correlated with higher levels of ferritin, C-reactive protein in both MIS-C and COVID-19 patients, and higher levels of D-dimer in MIS-C patients only. IL-6 was elevated in all patients, and did not worsen with degree of liver injury.

A substantially higher proportion of MIS-C patients were admitted to the ICU versus COVID-19 patients (about 54% vs 24%), though with similar proportions of patients with multi-organ failure (13.6% vs 13%). However, Cantor noted the small sample size of the MIS-C patients, and said the study may have been underpowered to detect differences in these outcomes.

She added COVID-19 patients with acute liver injury were more likely to be admitted to the ICU and have multi-organ failure.

And all six patient deaths in the cohort were from the COVID-19 group. All had pre-existing conditions; three had asthma and the two that had acute liver injury also had obesity.

While liver injury "may be a transient phenomenon, patients ... require careful monitoring during admission and long-term follow-up to ensure normalization," Cantor said.

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