Table 1.
Liver involvement of SARS-CoV-1, MERS, and SARS-CoV-2
| SARS-CoV-1 | MERS-CoV | SARS-CoV-2 | |
|---|---|---|---|
| Incidence of liver injury | 60% 6 | 60% 6 | 14.8–53% 8 |
| Expression of entry receptor on cholangiocytes | NA | NA | ACE2 receptor expression is higher than on hepatocytes 9 |
| Expression of entry receptor on hepatocytes | ACE2 receptor expression is abundant 9 | DPP-4 receptor expression is high in liver 10 | ACE2 receptor expression is low 9 |
| Expression of entry receptor in Kupffer cells, liver endothelial cells, and other inflammatory cells | NA | NA | ACE2 receptor is expressed 9 |
| Liver enzyme level | Mild to moderate elevation of ALT and AST—53% 11 | Elevation of ALT and/or AST 12, 13 | Elevation of ALT 23.3% and AST 23.4% 14 |
| Albumin level | Decreased serum albumin 1 | Decreased levels of albumin 12, 13, 15 | Decreased levels of albumin 61.3% 14 |
| Bilirubin level | Increased serum bilirubin 6 | Increased serum bilirubin 12, 13 | Increased serum bilirubin 27.9% 4 |
| Serum GGT level | NA | NA | Increased in severe cases 27.9% 14 |
| Pathological manifestations of liver injury | Antemortem Mild lobular activities with occasional acidophilic bodies and prominent Kupffer cell Mildly inflamed portal tracts with lymphocytic infiltration Nonspecific inflammation in the liver in biopsy Hydropic degeneration Steatosis Focal necrosis 6 Postmortem histopathological findings- Necrosis Nodular cirrhosis Minor inflammatory changes Hydropic and fatty degeneration Interstitial cell proliferation Mild fatty acid degeneration Mild congestion 6 Significant increase in mitotic cells with eosinophilic bodies and balloon-like hepatocytes 15 | Postmortem histopathological findings Mild chronic lymphocytic portal and lobular inflammation Reactive parenchyma with mild cellular hydropic degeneration Rare multinucleated hepatocytes and mild disarray of the hepatic plates Mild sinusoidal lymphocytosis and small necroinflammatory foci in the hepatic lobules Congestion, hemorrhage, and focal perivenular loss of hepatocytes Macrovesicular perivenular steatotic change, sinusoidal congestion, hemorrhage, and focal perivenular loss of hepatocytes Scattered calcifications Nonspecific hepatitis 6 | Postmortem histopathological findings Microvescicular steatosis Mild lobular and portal activity 16 Hepatomegaly Hepatocyte degeneration Lobular focal necrosis Neutrophil infiltration (lymphocytes and monocytes in portal area) Congestion of hepatic sinuses with microthrombosis Mild sinusoidal dilatation Mild lobular lymphocytic infiltration Patchy hepatic necrosis in the periportal and centrilobular areas Over activation of T cells 17 |
ACE2 = angiotensin-converting enzyme 2; ALT = alanine aminotransferase; AST = aspartate aminotransferase; DPP-4 = dipeptidyl peptidase 4; MERS-CoV = Middle East respiratory syndrome coronavirus; NA = not available/applicable; SARS-CoV-1 = severe acute respiratory syndrome coronavirus 1; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.