Drug-Induced Liver Injury After COVID-19 Vaccine

Authors: Monitoring Editor: Alexander Muacevic and John R AdlerRupinder Mann,1Sommer Sekhon,2 and Sandeep Sekhon3 Cureus. Published onlined doi: 10.7759/cureus.16491 PMCID: PMC8372667PMID: 34430106


The first case of coronavirus disease 2019 (COVID-19) was reported in December 2019 in China. World Health Organization declared it a pandemic on March 11, 2020. It has caused significant morbidity and mortality worldwide. Persistent symptoms and serious complications are being reported in patients who survived COVID-19 infection, but long-term sequelae are still unknown. Several vaccines against COVID-19 have been approved for emergency use around the globe. These vaccines have excellent safety profiles with few reported side effects. Drug-induced hepatotoxicity is mainly seen with different drugs or chemicals. There are only a few reported cases of hepatotoxicity with vaccines. We present a case of liver injury after administration of the vaccine against the COVID-19 infection.


A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) causing coronavirus disease 2019 (COVID-19) emerged in December 2019 in Wuhan, China, resulting in an ongoing pandemic [1]. To date, it has caused more than 173 million cases and over 3.7 million death worldwide as per World Health Organization [2]. Although the respiratory system is the most common system affected by this disease, it affects multiple organ manifestations [3]. Despite international efforts to develop treatments for this disease, there are still limited therapeutic options available with remdesivir as the only Food and Drug Administration-approved drug [4]. Given the rapid spread, high morbidity, and mortality worldwide, a coordinated effort led to developing the vaccine in a year of first diagnosed case. Multiple COVID vaccines have been developed at an unprecedented rate. These vaccines have excelled safety and efficacy profiles [57]. The most common adverse effects reported with these vaccines included mild effects like pain at the vaccine site, fever, fatigue, headache, arthralgia, myalgia, lymphadenopathy, and severe effects like anaphylactic reaction [8]. Drug-induced hepatotoxicity is a common adverse event seen with prescription and nonprescription drugs [9]. There are few reported hepatotoxicity cases due to vaccines, namely anti-rabies vaccination-induced hepatotoxicity and autoimmune hepatitis due to influenza virus and hepatitis A and B vaccines [1017]. We report a case of liver injury after receiving the COVID vaccine.Go to:

Case presentation

A 61-year-old female with a known history of irritable bowel disease and cholecystectomy presented to the emergency department with generalized weakness, body aches, dry heaving, and a low-grade temperature of 99.9 Fahrenheit. The patient received a second dose of the Pfizer COVID-19 vaccine nine days before the start of symptoms. She was noted to have conjunctival icterus, mild generalized abdominal tenderness without guarding, or rigidity on physical examination. On admission, the patient’s vitals were stable except for tachycardia with a heart rate between 90 and 110 beats/min.

Laboratory analysis was remarkable for elevated alkaline phosphatase (ALP) of 207 U/L, total bilirubin of 6.2 mg/dL, direct bilirubin of 3.9 mg/dL, white blood cell (WBC) count of 17.2 x 109/L, and mildly elevated aspartate transaminase of 37 U/L (Table ​(Table11 and Figure 1). Abdominal ultrasound showed increased echogenicity within the liver compatible with fatty infiltrates, and common duct diameter was measured to be 6 mm. At the same time, CT of the abdomen with contrast showed no acute abnormalities. The patient was admitted to the hospital and started on empiric antibiotics for presumed cholangitis. Gastroenterology consultation was obtained. Magnetic resonance cholangiopancreatography without contrast showed no filling defect within the biliary duct, status post cholecystectomy, bile duct diameter within a normal range, and unremarkable liver. The patient remained afebrile, WBC trended down, and abdominal pain improved over the course of the hospital stay. Given these findings, infectious disease specialist recommended discontinuing antibiotics. Antibodies to liver/kidney microsomal type 1, smooth muscle, anti-mitochondrial, alpha-1 antitrypsin came back negative, and, additionally, ceruloplasmin, antinuclear antibody, alpha-fetoprotein, and viral serologies for hepatitis A, B, and C came back negative (Table ​(Table2).2). Liver biopsy showed minimal pallor suggesting slight edema along with scattered inflammatory cells consisting of small lymphocytes, scattered polymorphonuclear leukocytes, and few eosinophils, no evidence of florid duct lesion on interface hepatitis, and no evidence of fibrosis on trichrome and reticulin stain. 

Table 1

Liver function tests trend

DateAspartate transaminase (U/L)Alanine transaminase (U/L)Total bilirubin (mg/dL)Alkaline phosphate (U/L)Albumin (g/dL)

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Table 2

Immunologic and infectious work-up for liver disease

Gamma-glutamyl transpeptidase103 U/L (1-24 U/L reference range)
Hepatitis A IgM antibodyNegative
Hepatitis B surface antigenNegative
Hepatitis B core IgM antibodyNegative
Hepatitis C antibodyNegative
Anti-liver/kidney microsomal antibodyNegative (≤20 = negative, reference range)
Ferritin975.2 ng/mL (10.0-291.0 reference range)
Antinuclear antibody reflexNegative
Smooth muscle antibodyNegative
Anti-mitochondrial antibodyNegative (≤20 = negative, reference range)
Ceruloplasmin38 mg/dl (18-53 mg/dL reference range)

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Figure 1

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Object name is cureus-0013-00000016491-i01.jpg

Graphs showing liver function test trends

Given that all work-up for infection, autoimmune diseases, and any obstruction came back negative, the patient’s clinical picture and laboratory findings were attributed as a liver injury due to the COVID-19 vaccine. Her liver function levels continued to trend down, and she was discharged from the hospital after a week of hospitalization. On the patient’s follow-up with a gastroenterologist, abdominal pain was resolved, and her liver function test values normalized (Table ​(Table11 and Figure ​Figure11).Go to:


Drug-induced hepatotoxicity leads to nearly 10% of all cases of acute hepatitis and more than 50% cases of liver failure [18]. It is one of the common reasons for the withdrawal of medications from the market and modification of use [19]. It can be either type A (predictable), dose-related and short latent period in days, or type B (idiosyncratic), dose-independent, unpredictable, and variable latency [20,21]. Based on population-based studies, drug-induced liver injury incidence varies between 13.9 and 19.1 cases per 100,000 people per year [22,23]. Patients have either hepatocellular injury (three times upper limit of transaminase in comparison to ALP), cholestatic injury (three times increase in ALP comparison to transaminase), or mixed pattern (where both ALP and aminotransferase are three times upper limit) [2426]. Most patients improve spontaneously after the removal of the offending drug. If acute liver failure (ALF) is suspected, early liver transplant referral is important due to high ALF mortality [25,27]. From the spontaneous reports from patients who received Pfizer/BioNTech BNT162b2 mRNA in the UK between 9/12/20 and 26/05/2021, there are reports of 45 patients having abnormal liver function analysis and three patients having drug-induced liver injury [28].

In this case, the review of medications and history did not reveal any other reason for hepatotoxicity. She also denied the use of any over-the-counter medications or supplements. Although it is rare with vaccination, the COVID-19 vaccine is likely the cause of hepatotoxicity in our patient based on a diagnosis of exclusion. In this case, the patient had a cholestatic pattern with elevated ALP and bilirubin with mild elevation in the transaminases.

Pfizer/BioNTech BNT162b2 mRNA trial included only 0.6% (217/37,706) patients with liver disease. Among patients with liver disease, 214 were with mild liver disease and only three with moderate to severe liver disease. This patient has underlying fatty liver disease. It is unclear if that was a likely risk factor for hepatotoxicity in this case [5].  Although only a small number were included in trials for Pfizer/BioNTech BNT162b2 mRNA, Moderna mRNA-1273, and the AstraZeneca/University of Oxford ChAdOx1-nCoV-19 chimpanzee adenovirus vector vaccine, both the American Association for Study of Liver Diseases and European Association for the Study of Liver recommend vaccination against SARS-COV-2 with these highly effective and safe vaccines, given a greater risk of health consequences from SARS-COV-2 infection in these patients [29,30].

Hepatotoxicity can occur with vaccines, even though it is more common with prescription and nonprescription drugs. So, the clinician should be watchful in patients showing clinical signs and symptoms after a vaccine.Go to:


In summary, we presented a case of liver injury after the COVID-19 vaccine. We attributed the cause of liver injury to the COVID-19 vaccine, given no other cause in our patient after extensive work-up. There are reports of drug-induced liver injury and abnormal liver function analysis from the spontaneous reports from patients who received Pfizer/BioNTech BNT162b2 mRNA COVID-19 vaccine in the UK. The purpose of this manuscript is to raise awareness of potential side effects; it should not alter the recommendation of healthcare providers regarding vaccinations.Go to:


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Liver injury after mRNA-based SARS-CoV-2 vaccination in a liver transplant recipient

Authors: Jérôme Dumortiera,b,⁎ Clin Res Hepatol Gastroenterol. 2022 Jan; 46(1):101743.16.  doi: 10.1016/j.clinre.2021.101743 PMCID: PMC8214934PMID: 34146727

Coronavirus disease-2019 (Covid-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is an ongoing global pandemic of major concern, started at the end of 2019. Patients with comorbidities are at high risk of developing severe disease and this includes solid organ transplant recipients [1]. Therefore, Covid-19 vaccine is highly recommended in this population. Neverthless, immunocompromised patients, including solid organ transplant recipients, were not included in the Covid-19 vaccine large trials, especially of Pfizer/BioNTech and Moderna mRNA vaccines, and therefore, safety and efficacy data are lacking in this population. Recently, a significantly reduced immunogenicity of the mRNA SARS-CoV-2 vaccines has been reported [2,3]. Regarding the massive number of patients receiving this vaccination, identification of clinically relevant imputable side-effects of the vaccines is very difficult and therefore a major goal.

Herein we report the case of a 46-year-old male, who received the first injection of BNT162b2 mRNA vaccine 123 days after a liver transplantation for alcohol-associated liver disease. At the time of vaccination, the patient was on maintenance immunosuppression therapy with tacrolimus and mycophenolate mofetil, and liver function tests were within normal range. According to systematic biological follow-up, 12 days after vaccination, laboratory findings were as follows: AST 99 U/l (normal: 10–45), ALT 287 U/l (normal: 10–45), alkaline phosphatase (ALP) 270 U/l (normal: 38–120), gamma glutamyl transferase (GGT) 797 U/l (normal: 7–65), total bilirubin 9 mmol/l (normal: 0–20). The patient was totally asymptomatic. Serum HBsAg, anti-HBs, anti-HBc IgM, anti-HAV IgM, anti-HEV IgM, EBV-DNA (PCR), CMV-DNA (PCR), antinuclear antibody, anti-smooth muscle antibody, and anti-liver kidney microsomal antibody were negative. The patient did not consume alcohol on a regular or irregular basis. Other than immunosuppressive treatments included only aspirin. Abdominal Doppler ultrasound was normal. The diagnosis of liver damage related to vaccination was considered and no further investigation was performed, including no liver biopsy. Similarly, no modification of immunosuppressive regimen was done. The second vaccine injection was contra-indicated. Biological evolution was rapidly favourable. One month after initial biological liver injury, laboratory findings were as follows: AST 19 U/l (normal: 10–45), ALT 24 U/l (normal: 10–45), ALP 117 U/l (normal: 38–120), GGT 101 U/l (normal: 7–65), total bilirubin 8 mmol/l (normal: 0–20).

We report herein the case of a liver transplant recipient who presented mild liver injury probably due to the first injection of BNT162b2 mRNA vaccine. Evolution was spontaneously favourable. Perturbation of liver function tests was transitory, but detected because of regular systematic (monthly) biological follow-up, less than one year after transplantation. In this context, such diagnosis must be considered together with more usual cause of liver graft injury, such as rejection, in face of significant liver function test abnormalities. Moreover, in the absence of severe liver injury, deleterious manoeuvres (diagnostic or therapeutic) must be ovoid and close biological follow-up performed. The most intuitive expected toxicity of mRNA vaccine (but also all vaccines) is related to immune activation. Therefore, benign and common reported symptoms include soreness, fatigue, myalgia, headache, chills, fever, joint pain, nausea, muscle spasm, sweating, dizziness, flushing, feelings of relief, brain fogging, anorexia, localized swelling, decreased sleep quality, itching, tingling, diarrhoea, nasal stuffiness and palpitations [4]. The flip side of the possibly beneficial adjuvant inflammation, however, is potential toxicity of the mRNA vaccines. And remember that this type of vaccine has also been evaluated as an anti-cancer treatment. With the Covid-19 vaccines, we are using this new type of vaccine for the first time on a very large scale. From preliminary animal and human studies on previous mRNA vaccines, the clinical adverse effects have included myopathy (caused by mitochondrial toxicity), lipodystrophy, lactic acidosis, pancreatitis, liver steatosis, and nerve damage and some were severe [5]. A better understanding of the toxicity of Covid-19 vaccines, particularly mRNA vaccines, can only be based on comprehensive reporting of even apparently mild cases. These cases will be more easily identified in special populations under close clinical and biological surveillance, such as transplant patients, as reported in our patient. Perhaps these patients are also at greater risk.Go to:


Conflicts of interest and sources of funding: None to declare.

Author contributions: J.D. clinically managed the patient and wrote the manuscript.Go to:


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How the Pfizer-BioNTech COVID-19 vaccine affects human liver cells

Authors: Lund University MARCH 10, 2022 Medical Xpress

A recent study from Lund University in Sweden on how the Pfizer-BioNTech COVID-19 vaccine affects human liver cells under experimental conditions, has been viewed more than 800,000 times in just over a week. The results have been widely discussed across social media—but the results have in many cases been misinterpreted. Two of the authors, Associate Professor Yang de Marinis (YDM) and Professor Magnus Rasmussen (MR), share their views.

How did this study come about?

YDM: A previous study from MIT has indicated that the SARS-CoV-2 virus mRNA can be converted to DNA and integrated into the human genome. Indeed, about 8 percent of human DNA comes from viruses inserted into our genomes during evolution. Does the Pfizer-BioNTech mRNA vaccine get converted to DNA or not? This has been the question our study aims to answer.

What did your study conclude?

YDM: This study does not investigate whether the Pfizer vaccine alters our genome. Our publication is the first in vitro study on the conversion of mRNA vaccine into DNA, inside cells of human origin. We show that the vaccine enters liver cells as early as six hours after the vaccine has been administered. We saw that there was DNA converted from the vaccine’s mRNA in the host cells we studied.

MR: These findings were observed in petri dishes under experimental conditions, but we do not yet know if the converted DNA is integrated into the cells’ DNA in the genome—and if so, if it has any consequences.

Why liver cells and why the specific dose?

YDM: About 18 percent of the vaccine accumulates in the liver just 30 minutes after the vaccine is injected in mice as reported by Pfizer in EMA assessment report, and therefore we chose to study liver cells. This also explains the choice of vaccine concentrations in our study, something we specifically address in the paper, which are 0.5–2% of the injection site concentration.

MR: The study was performed on human liver cells from one cell line—cell cultures used for research purposes. It is a good tool when studying molecular and cellular processes, they are easy to research, and since the cell lines are easily accessible, studies often start with various cell lines.

What are key limitations of the study?

MR: One should consider that cell lines differ from cells in living organisms, and therefore it is important that similar investigations are also studied in humans.

It is important to bear in mind that the liver cells in this study are more genetically unstable than our own liver cells.

YDM: One of the limitations of our study is that we don’t know if what we observed in this cell line could also happen in cells of other tissue types, and this needs to be addressed in follow-up studies.

The study has received a lot of media attention, what are your thoughts on that?

MR: We understood that the study would attract attention, but we think it is self-evident that this type of research should be pursued. We have a new vaccine, and it needs to be tested in cell and animal models and also in humans, in various ways. The result might be surprising, but it is also a bit surprising that such studies do not seem to have been carried out before.

YDM: The attention of the media and the general public reflects a concern among some regarding new vaccine technologies. This in itself motivates the need for further studies.

Based on this study, is there any reason to not get vaccinated?

MR: There is no reason for anyone to change their decision to take the vaccine based on this study.

What are the next steps in this research?

YDM: More research is needed. Data, especially data from vaccinated humans, will hopefully sort out the question marks. Whether our results are true for other cell types in humans, or if they are specific to mRNA vaccines, are among many questions for further research.

About the study:

In a lab environment, i.e., in petri dishes, the researchers added Pfizer BioNTech’s vaccine to a cell line that originally came from a human liver tumor.

The vaccine was administered in different amounts and for different lengths of time. Cells that received no vaccine at all were used for control purposes. The researchers then investigated how different gene expressions in the cells changed over time. A gene that the researchers studied produces the protein LINE-1.

“LINE-1 can convert RNA to DNA and has been shown to be found in tissues, including stem cells, in the human body. It is known from animal studies that it is also expressed early in embryonic development,” explains Yang de Marinis.

Nonintegrating Direct Conversion Using mRNA into Hepatocyte-Like Cells

Authors:: angtae Yoon, 1 , 2 Kyojin Kang, 1 , 2 Young-duck Cho, 3 Yohan Kim, 1 , 2 Elina Maria Buisson, 1 , 2 Ji-Hye Yim, 1 , 2 Seung Bum Lee, 4 Ki-Young Ryu, 5 Jaemin Jeong, 1 , 2 and Dongho Choi 1 , 2 Biomed Res Int. 2018; 2018: 8240567.Published online 2018 Sep 20.doi:  10.1155/2018/8240567 PMCID: PMC6171260PMID: 30327781


Recently, several researchers have reported that direct reprogramming techniques can be used to differentiate fibroblasts into hepatocyte-like cells without a pluripotent intermediate step. However, the use of viral vectors for conversion continues to pose important challenges in terms of genome integration. Herein, we propose a new method of direct conversion without genome integration with potential clinical applications. To generate hepatocyte-like cells, mRNA coding for the hepatic transcription factors Foxa3 and HNF4α was transfected into mouse embryonic fibroblasts. After 10-12 days, the fibroblasts converted to an epithelial morphology and generated colonies of hepatocyte-like cells (R-iHeps). The generated R-iHeps expressed hepatocyte-specific marker genes and proteins, including albumin, alpha-fetoprotein, HNF4α, CK18, and CYP1A2. To evaluate hepatic function, indocyanine green uptake, periodic acid-Schiff staining, and albumin secretion were assessed. Furthermore, mCherry-positive R-iHeps were engrafted in the liver of Alb-TRECK/SCID mice, and we confirmed FAH enzyme expression in Fah1RTyrc/RJ models. In conclusion, our data suggest that the nonintegrating method using mRNA has potential for cell therapy.

1. Introduction

Liver disease is a serious public health issue worldwide because of its high prevalence and poor long-term prognosis including cirrhosis, hepatocellular carcinoma, and premature death from liver failure [12]. Furthermore, injuries with acquired, traumatic, or genetic etiologies can prevent the liver from performing a number of functions such as storing, detoxifying, and producing bile fluid and clotting factors and metabolic activities resulting in end-stage liver disease which ultimately requires liver transplantation [35]. Therefore, generating large quantities of hepatocytes is of paramount importance for scientists and clinicians. The ability of stem cells to be used in cell therapy has enormous potential [6]. Pluripotent stem cells have been used to generate hepatocyte-like cells [710]. Despite the usefulness of pluripotent stem cells, the risk of tumor formation [1112], long-term differentiation failure [13], and low differentiation efficiency [14] have emerged as points of controversy. The direct conversion of fibroblasts into target cells became feasible through lineage-specific transcription factors (TFs), and the direct conversion process is simpler and faster than induced pluripotent stem cell (iPSC) generation [1516]. Direct conversion of one cell type into another without using a pluripotent intermediate is a promising practical source for invaluable cells such as hepatocytes [17].

Compared to pluripotent stem cell differentiation, direct reprogramming has a number of advantages, including the lack of tumorigenic risk [18], a fast conversion rate [19], and the promise of injured tissue repair using in vivo reprogramming [2021]. Recently, a number of studies have investigated the results of direct conversion by RNA in cells such as neurons and cardiomyocyte-like cells [2223]; however, insufficient studies have been carried out in hepatocytes. We propose a method of functional hepatocyte generation suitable for engrafting in a damaged liver animal model, in which modified mRNA is used to overexpress reprogramming factors without genomic modification.

2. Materials and Methods

2.1. mRNA Synthesis by In Vitro Transcription (IVT)

To make mRNAs, template DNAs were obtained from Foxa3 and HNF4α plasmid. mRNAs were transcribed in vitro from 1.5 ug of each DNA template and synthesized using the MEGAscript T7 kit (Ambion, Austin, TX, USA), per each 40 ul of reaction buffer. IVT reactions were mixed with 2 ul of each NTP and incubated between 2 and 4 hrs at 37°C. To remove the template DNAs, 1ul of TURBO DNase was used after IVT reaction and incubated for 15 min at 37°C and purified with 70% EtOH for 5 min. Reacted mRNAs were capped during m7G capping and 2′-O-Methylation (ScriptCap m7G capping system and 2′-O-Methyltransferase kit, CELLSCRIPT, Madison, WI, USA), subsequently tailed (A-Plus Poly (A) Polymerase Tailing kit; CELLSCRIPT), and repurified as previously described. mRNA length was confirmed using 1% LE Agarose Gels (GenomicsOne Co. Ltd., Seoul, Korea). RNA concentrations were calculated with the use of Nanodrop and were adjusted to 200-300 ng/ul by adding Nuclease-free water (Ambion). As a control, eGFP mRNA was used and the expression of eGFP was observed and compared with Foxa3 and HNF4α.

2.2. Modified mRNA Transfection

To generate R-iHeps, mouse embryonic fibroblasts (MEFs) were cultured in Dulbecco’s Modified Eagle’s Medium (Life Technologies, Carlsbad, CA, USA) supplemented with 10% fetal bovine serum, 3.14 uM β-mercaptoethanol (Sigma-Aldrich, St. Louis, MO, USA), and 1% penicillin/streptomycin (Life Technologies) at 37°C in a CO2 incubator. Lipofectamine 2000 (Life Technologies) was used for mRNA transfection.  On day 0 and 3, 1.5 ug of Foxa3 and HNF4α mRNA each and 3 ul of lipofectamine 2000 were diluted in a mixture of 125 ul of Opti-MEM reduced serum media (Life Technologies) in separate tubes. They were then mixed together into one tube and were incubated at room temperature for 5 minutes. In a culture dish, 250 ul of the incubated mixture was added in 1ml of cell growth media and was incubated at 37°C for 4 hours. After 24 hours, the medium was changed with DMEM/F-12 (Life Technologies) supplemented with 10% fetal bovine serum (Life Technologies), 10mM Nicotinamide (Sigma-Aldrich), 0.1 uM dexamethasone (Sigma-Aldrich), 1% Insulin-Transferrin-Selenium-X Supplement (Life Technologies), 1% penicillin/streptomycin (Life Technologies), 20 ng/ml hepatocyte growth factor (Peprotech, Rocky Hill, NJ, USA), and 20 ng/ml epidermal growth factor (Peprotech). The medium was changed every two days.

2.3. Quantitative Real-Time PCR

One ug of mRNA isolated with Trizol reagent (Life Technologies) was reverse transcribed with the Transcriptor First Strand cDNA Synthesis Kit (Roche, Basel, Switzerland). Then, quantitative real-time PCR was performed using 10 ul of qPCR PreMix (Dyne Bio, Seongnam-si, Gyeonggi-do, Korea), 1 ul cDNA, and oligonucleotide primers on a CFX Connect Real-Time PCR Detection System (Bio-Rad, Hercules, CA, USA). Reactions were analyzed in triplicate for each gene. A total of 40 PCR cycles were performed, each cycle at 95°C for 20 sec, then 60°C for 40 sec. Melting curves and melting peak data were obtained to characterize PCR products. All primers are shown in Supplementary Table 1.

2.4. Immunostaining

The cells were fixed in 4% paraformaldehyde in phosphate buffered saline (PBS, pH 7.4) for 20 min at room temperature. The fixed cells were washed twice with a staining solution of PBS containing 1% fetal bovine serum for 5 min and then permeabilized with 0.25% Triton X-100 for 30 min at room temperature. Thereafter, the cells were incubated overnight at 4°C with the following primary antibodies: anti-albumin, E-cadherin, CK18, HNF4a, CYP1A2, ASGR1, Hep par-1, AFP, and vimentin (Table S2). The next day, cells were washed three times with a staining solution, and the appropriate fluorescence labeled Alexa-Fluor secondary antibody was added and incubated for 2 hours, in the dark, at room temperature. The nucleus was counterstained with Hoechst 33342 (Invitrogen, Carlsbad, CA, United States).

2.5. ICG Uptake and PAS Staining

For the indocyanine green (ICG) uptake assay, the cells were incubated for 15 min at room temperature with 1mg/ml DID Indocyanine Green Inj. (Dongindang Pharmaceutical, Siheung-si, Gyeonggi-do, Korea) and washed three times with PBS. For periodic acid-Schiff (PAS) staining, Periodic Acid-Schiff staining kit (Abcam, Cambridge, UK) was used. First, the cells were fixed with 4% paraformaldehyde in PBS for 20 min at room temperature. These fixed cells were rinsed in slow running tap water and then exposed to periodic acid solution for 5 min at room temperature. After being washed four times with distilled water, the cells were treated with Schiff’s reagent for 15 min at room temperature and washed three times with distilled water. Thereafter, the cells were stained with hematoxylin (Modified Mayer’s) for 2 min and washed three times with distilled water. A bluing reagent was applied for 30 sec to clearly identify the stained cells.

2.6. Albumin Secretion

To assess the function of these R-iHeps, we measured the secretion of the most well-known hepatic marker, albumin. Albumin secretion in R-iHeps was done according to the manufacturer’s protocol using the Mouse Albumin ELISA kit (Bethyl Laboratories, Montgomery, TX, USA). Media was collected every two days and were stored at -80°C. The undiluted samples were measured in duplicate following the protocol’s suggestion.

2.7. In Vivo Experiment

To determine whether R-iHeps can engraft and differentiate into functional hepatocytes in vivo, we used a liver injury mouse model, Alb-TRECK/SCID (kind gift from Taniguchi Hideki, Yokohama City University, Japan) and Fah1RTyrc/RJ (kind gift from Hyongbum (Henry) Kim, Yonsei University). The animal experiments were performed in accordance with the Center for Laboratory Animal Sciences, the Medical Research Coordinating Center, and the HYU Industry-University Coordinating Foundation regulations (2016-0212A, 2017-0055A). To induce liver injury, Alb-TRECK/SCID mice were intraperitoneally injected with 2 ug/kg of diphtheria toxin (Sigma-Aldrich) 2 days before transplantation. Liver damage was also induced in Fah1RTyrc/RJ mice by withdrawing NTBC ((2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione)) 24 hrs before transplantation. mCherry-positive R-iHeps were obtained via FACS sorting and were transplanted through the spleen of the mouse (5×105 cells/mice). Alb-TRECK/SCID and Fah1RTyrc/RJ mice were sacrificed at 48 hrs and three weeks after transplantation, respectively.

3. Results

3.1. In Vitro Transcription and Expression of mRNA

To synthesize mRNA of Foxa3 and HNF4α, we cloned cDNA into pcDNA/UTR120A (Figure 1(a)). We conducted in vitro transcription using T7 polymerase and then modified synthesized mRNA. Synthesized mRNA is loaded in 1.5% agarose gels to confirm mRNA degradation. Foxa3 and HNF4α mRNA are synthesized to full length and not degraded (Figure 1(b)). mRNA stability and expression are evaluated for GFP mRNA transfection into MEFs (Figure 1(c)). After GFP mRNA transfection, GFP fluorescence was detected on day 1 and 3 under fluorescence microscope. However it almost disappeared on day 7.  The transfection efficiency of GFP mRNA was 18.53% onday 1 (Figure 1(d)). Therefore we decided transfection time of Foxa3 and HNF4α mRNA on day 0 and 3 to convert them into hepatocyte-like cells.Open in a separate windowFigure 1

Transcription and expression of modified mRNA of HNF4α and Foxa3. (a) Scheme of in vitro transcription and modification of mRNA. (b) Gel loading of HNF4α and Foxa3 mRNA. (c) One time transfection and protein expression of green fluorescence protein mRNA into MEFs for 7 days. Green fluorescence was detected under fluorescence microscope. Scale bars: 100 um. (d) Analysis of transfection efficiency of GFP mRNA by Flow Cytometry.

3.2. Generation of R-iHeps from MEFs and Morphogenesis of Hepatocyte-Like Cells

In order to generate hepatocyte-like cells, Foxa3 and HNF4α mRNA were transfected into mouse embryonic fibroblasts (MEFs) for 4 hours at temperature of 37°C (Figure 2(a)) on day 0 and 3. Two days after transfection, we switched media to direct conversion media for effective conversion into hepatic lineage. On day 6, MEFs started moving and switching morphology steadily (Figure 2(b)). Finally we found epithelial colonies similar with hepatocyte which are plentiful cytosol, small nuclei, and forming bile canaliculi after 12 days after transfection. These results suggest that directly converted R-iHeps are effective for generating hepatocyte-like cells from MEFs using mRNA.Open in a separate windowFigure 2

Generation of R-iHeps using mRNA from MEFs. (a) Scheme of generation of R-iHeps. mRNAs of modified HNF4α and Foxa3 were transfected with lipofectamine on day 0 and 3. MEFs: mouse embryonic fibroblasts; R-iHeps: RNA induced hepatocyte-like cells. (b) The morphology of directly converted R-iHeps by mRNA. On day 12, R-iHeps were shown and grown. Insets: higher magnification of the boxed areas. Scale bars: 100 um.

3.3. Acquisition of Hepatic Characteristics of R-iHeps

To gain a better understanding of R-iHeps characteristics, we performed quantitative real-time PCR (qPCR) of hepatocyte-specific genes. Albumin, alpha-fetoprotein (AFP), HNF4α, CK18, and CYP1A2 expressions were markedly increased in R-iHeps as compared to MEFs (Figure 3(a)). Also, these genes’ expressions were similar to miHeps which were generated using Foxa3 and HNF4α retrovirus [2425] and were correlated with protein expression (Figure 3(b)). Albumin, E-cadherin, CK18, HNF4α, CYP1A2, ASGR1, Hep par-1, and AFP were expressed in R-iHeps but not MEFs. Vimentin which is a fibroblast marker was only stained in MEFs. To evaluate hepatic function of R-iHeps in vitro, glycogen storage was revealed through Periodic Acid-Schiff (PAS) staining by more than 70% of the glycogen storage in R-iHeps and increased uptake of Indocyanine green (ICG) uptake compared to MEFs. This proved the xenobiotic metabolic activities in more than 50% of the R-iHeps which showed effective hepatic function (Figure 3(c)). In addition, the albumin secretion rate of R-iHeps was measured by Enzyme-Linked Immunosorbent Assay (ELISA) in the culture media (Figure 3(d)). Albumin secretion of R-iHeps (1×105 cells) rapidly increased six days after seeding. This indicates that R-iHeps secrete albumin abundantly after stabilization period. These findings demonstrate that R-iHeps generated by the mRNA of Foxa3 and HNF4α could be another cell source of hepatocyte-like cells representing hepatic marker gene, protein expression, and a gain of hepatic function.Open in a separate windowFigure 3

Analysis of hepatic characteristics of R-iHeps. (a, b) Comparison of hepatic gene and protein marker expression of R-iHeps and MEFs. (a) Expression levels of hepatic marker genes in R-iHeps (red bar) as determined by qPCR. Albumin, AFP, HNF4α, CK18, and CYP1A2 expression were increased in R-iHeps. MEFs: mouse embryonic fibroblasts; R-iHeps: RNA induced hepatocyte-like cells; miHeps: directly converted hepatocyte-like cells using retrovirus; mPHs: mouse primary hepatocytes. , p<.05; , p<.01; , p<.001. (b) Albumin (green)/E-cadherin (red), CK18 (green)/HNF4α (red), CYP1A2 (green)/ASGR1 (red), and Hep par-1 (green)/AFP (red) protein expression were detected in R-iHeps. Vimentin which is a fibroblast marker was detected not in R-iHeps but MEFs. Hoechst (blue) labels all nuclei. The images were captured using confocal microscopy. Scale bars: 50 um. (c) Confirmation of hepatic transporter function and presence of glycoprotein in R-iHeps by indocyanine green (ICG) uptake and Periodic Acid-Schiff (PAS) staining, respectively. (d) Measurement of secreted albumin in the culture media in vitro by ELISA. , p<.001.

3.4. In Vivo Transplantation of R-iHeps

Finally, we implanted R-iHeps into two fulminant hepatic failure models to test whether engraftment and differentiation into functional hepatocytes in damaged liver could occur. First, we used Alb-TRECK/SCID model mice which were injured by diphtheria toxin (DT) [26]. mCherry tagged R-iHeps (5X105 cells/mice), labeled for easy tracing in vivo, were administrated into the spleen 48 hrs after DT injection (2 ug/kg). At two days after transplantation, livers were harvested and sectioned. Histologically damaged liver (PBS injection group) showed disrupted cell junctions, necrotic cells were also found in H&E staining, and albumin expression was significantly decreased as seen through many unstained hepatocytes observed under confocal microscopy as compared to normal and R-iHeps injection groups (Figure 4(a)). On the other hand, in R-iHeps injection group, albumin positive hepatocytes costained with mCherry were found around blood vessels. In addition, liver structure was recovered by R-iHeps injection as shown in H&E staining. To prove the above data, R-iHeps were transplanted into Fah1RTyrc/RJ mice model which was damaged by the withdrawal of NTBC ((2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione)) [27]. Being transplanted after three weeks, R-iHeps and mouse primary hepatocytes (mPHs) were detected through fumarylacetoacetate hydrolase (FAH) enzyme (Figure 4(b)). Fah1RTyrc/RJ mice model did not express FAH, but R-iHeps or mPHs transplanted mice liver produced FAH enzyme. Taken together, these results suggest that mRNA induced hepatocyte-like cells (R-iHeps) not only are transplantable in fulminant damaged liver, but also express the hepatic specific enzyme in vivo. Therefore, R-iHeps might be another cell source for liver regeneration.Open in a separate windowFigure 4

In vivo transplantation of R-iHeps. (a) mCherry labeled R-iHeps (5X105 cells/100 ul) transplanted into Alb-TRECK/SCID mice via intrasplenic injection. Alb-TRECK/SCID mice were liver damaged by diphtheria toxin (DT, 2 ug/kg) 48 hrs before cell transplantation. All histological data were shown at 48 hrs after cell transplantation. Normal group: no DT administered; PBS group: PBS injection only after DT injury; R-iHeps group: R-iHeps injection after DT injury. Hoechst 33342 (blue) labels all nuclei. Scale bars in H&E staining picture: 100 um; scale bars in fluorescence pictures: 50 um. (b) R-iHeps (5X105 cells/100 ul) transplanted into Fah1RTyrc/RJ mice via intrasplenic injection. Fah1RTyrc/RJ mice were liver damaged by NTBC ((2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione)) withdrawal 24 hrs before cell injection. PBS group: PBS injection only; R-iHeps group: R-iHeps injection; mPHs group: mouse primary hepatocytes (5X105 cells/100 ul) injection. Detection of FAH enzyme expression by immunoperoxidase staining at 3 weeks after transplantation. Scale bars: 100 um.

4. Discussion

Patients with end-stage chronic liver disease generally require liver transplantation as the sole definitive method of treatment [2829]. Potential liver transplant recipients are outstripping possible donors [30]. Numerous studies have investigated ways to surmount this shortage [3]. The introduction of lineage-specific TFs into somatic cells enabled distinct cellular identities to be introduced, while bypassing a pluripotent stem cell state [3134]. However, viral transduction systems have the potential risk of insertional mutations and integration-associated genotoxicity [3538]. We propose a simple method of forming hepatocyte-like cells without relying on retroviral vectors. Our method successfully induced direct reprogramming of mouse embryonic fibroblasts into R-iHeps by mRNA transfection. Our data proved that R-iHeps, functionally similar to hepatocytes, were produced through direct reprogramming with mRNA. The R-iHeps showed a markedly increased expression of albumin and AFP, which are widely known as hepatocyte-specific proteins, while the expression of fibroblast-specific proteins such as vimentin decreased. In addition, PAS staining showed an increase in glycogen storage capacity, and ICG uptake confirmed that the cells effectively performed hepatic functions. Increases in albumin secretion and urea synthesis were confirmed by ELISA.

5. Conclusion

This study showed that mRNA can be utilized for direct hepatocyte reprogramming and that this technique is beneficial because it allows accurate control of reprogramming factors. As it has a number of advantages over traditional methods using retroviral vectors, our model has revealed a new paradigm with exciting potential for cell therapy with clinical applications.


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Clinical update on risks and efficacy of anti-SARS-CoV-2 vaccines in patients with autoimmune hepatitis and summary of reports on post-vaccination liver injury

Authors: Ana Lleo 1Nora Cazzagon 2Cristina Rigamonti 3Giuseppe Cabibbo 4Quirino Lai 5Luigi Muratori 6Marco Carbone 7Italian Association for the Study of the LiverAffiliations expand PMID: 35410851 PMCID: PMC8958090DOI: 10.1016/j.dld.2022.03.014 Published:March 27, 2022DOI:https://doi.org/10.1016/j.dld.2022.03.014


Patients with liver diseases, especially those with cirrhosis, have an increased mortality risk when infected by SARS-CoV-2 and therefore anti-SARS-CoV-2 vaccine has been recommended by leading Scientific Associations for all patients with chronic liver diseases. However, previous reports have shown a reduced antibody response following the full course of vaccination in immunosuppressed patients, including liver transplant recipients and several rheumatic diseases.This document, drafted by an expert panel of hepatologists appointed by the Italian Association for the Study of the Liver (AISF), aims to present the updated scientific data on the safety and efficacy of anti-SARS-CoV-2 mRNA vaccines in patients with autoimmune hepatitis (AIH). Furthermore, given the recent reports of sporadic cases of AIH-like cases following anti-SARS-CoV-2 mRNA vaccines, we summarize available data. Finally, we provide experts recommendations based on the limited data available.

1. 2022 AISF recommendation on anti-SARS-CoV-2 vaccines for patients with known autoimmune hepatitis

Patients with chronic liver diseases (CLD), especially those with cirrhosis, have an increased mortality risk when infected by SARS-CoV-2 [[1]]. One of the largest international studies currently available, showed an observed mortality of 32% in patients with cirrhosis compared to 8% in those without [[2]]. Therefore, the European Association for the Study of the Liver (EASL) has recommended vaccination against SARS-CoV-2 for all patients with CLD [[3]]. Although contrasting data have been published, patients with AIH with or without cirrhosis under immunosuppressive therapy represent an at-risk category of developing severe COVID-19 when infected [[4],[5]]. Therefore, based on the data available, the benefit of anti-SARS-CoV-2 vaccination outweighs the potential risk for disease exacerbation in AIH.Although the registration trials of mRNA vaccines enrolled patients with CLD (217 patients in Pfizer trial and 196 patients in Moderna trial), subjects under immunosuppressive therapy were excluded. A recent study by Thuluvath and colleagues found that 75% of patients with CLD without cirrhosis and 77% of patients with cirrhosis had adequate antibody response to anti-SARS-CoV2 vaccines [[6]]. The authors included 233 patients with CLD with 61 being affected by immune mediated liver diseases, including AIH, primary biliary cholangitis, and primary sclerosing cholangitis. Also 62 patients were liver transplant (LT) recipients, 79 had cirrhosis, and 92 had CLD without cirrhosis. Antibody levels were undetectable in 11 patients who had LT, 3 with cirrhosis, and 4 without liver cirrhosis. LT and treatment with two or more immunosuppressive drugs were associated with poor antibody responses. However, only 3 patients out of 18 with undetectable antibody were AIH patients on immunosuppression (2 on prednisone plus mycophenolate mofetil (MMF) and 1 on prednisone plus azathioprine).Reports have shown a reduced antibody response following the full course of vaccination in liver transplant recipients [[7]]. It has also been formerly demonstrated that specific drugs (i.e. methotrexate, abatacept, and rituximab) reduced the immune response to influenza or pneumococcal vaccines in a number of different rheumatic diseases [8910]. The efficacy of anti-SARS-CoV-2 vaccination in preventing COVID-19 in patients with AIH on immunosuppressive therapies [[11],[12]], as well as the risk of disease reactivation after anti-SARS-CoV-2 vaccination, have been poorly investigated. Similarly, cellular immunity to SARS-CoV-2 in AIH patients has not been studied.The American College of Rheumatology (ACR) has recently proposed a guidance [[13]] suggesting a short-term withdrawal of methotrexate, JAK inhibitors, abatacept, and MMF, and deferral of rituximab and cyclophosphamide infusion if possible before anti SARS-Cov-2 vaccination, according to rheumatic disease activity. However, there is no solid evidence as to whether it is appropriate or not to suspend or reduce the dose of immunosuppressive drugs immediately before or following the administration of the vaccine in AIH patients. Importantly, this strategy may be potentially associated with an increased risk of AIH reactivation particularly dangerous in patients with cirrhosis. Of interest, high doses of MMF and rituximab remain independent predictors of failure to develop an antibody response after vaccination in rheumatic diseases [[14]]; however, no data are available in AIH. At the present time, the available data do not justify withdraw or reduction of immunosuppression before or immediately after vaccination in patients with AIH.Finally, no clear evidence of reactivation of AIH after anti-SARS-CoV-2 vaccination has been reported in the literature. Interestingly, the presence of significant fibrosis at the liver histology of a small number of newly diagnosed AIH following anti-SARS-CoV-2 vaccination might suggest the possibility of disease reactivation [151617]. However, until new multicenter studies are available there is no current indication for routine testing of transaminases levels in AIH patients after vaccination.

2. 2022 aisf recommendation on autoimmune hepatitis like onset following anti-SARS-CoV-2 vaccination

The COVID-19 pandemics has necessitated the development and registration of several vaccines in record time. The monitoring for safety, side effect and efficacy is ongoing in the post-marketing surveillance. Recent reports inform on the possible occurrence of immune mediated hepatitis or AIH-like disease in predisposed individuals. Autoimmunity is widely accepted to develop in genetically predisposed individuals and some polymorphisms have been identified in AIH [[18]]; unfortunately, they are not yet of clinical use and cannot be of help to identify individuals at risk.Considering that 58% of the world population has received at least one dose of anti-SARS-CoV-2 vaccine, with 9.2 billion doses been administered globally, it is unclear whether this is a pure coincidence rather than a causality.The fact that someone developed immune-mediated acute hepatitis after vaccination does not necessarily mean that this was caused by the vaccine.The European Medicine Agency (EMA)’s Pharmacovigilance Risk Assessment Committee (PRAC) has recently started an assessment following the very small number of cases reported after vaccination with Spikevax and Comirnaty (known as Moderna and Pfizer vaccines, respectively) in the medical literature and EudraVigilance (www.ema.europa.eu). Further data and analyses have been requested from the marketing authorization holder to support the ongoing assessment by PRAC. Given the small number of cases currently reported, the issue seems to be rare; however, specific studies should be performed to define the number and severity of cases.At the time these recommendations are drafted, 17 reports have been published in the medical literature that overall include 31 cases of suspected AIH-like triggered by the vaccine (Table 1). Patients were more often women (F:M 21:10), age ranging from 32 to 89 years old (median 58 years). In eleven cases a pre-existent autoimmune condition (i.e., seven Hashimoto thyroiditis, one primary biliary cholangitis, two rheumatoid arthritis, one systemic lupus erythematosus) is reported. Two patients had experienced COVID-19 infection before the vaccine. All except four presented with an acute onset of AIH-like with jaundice. All patients underwent liver biopsy and in six of them fibrosis was already present, which might suggest that they had a previous liver disease, possibly an undiagnosed AIH. All were treated with steroid therapy, and all improved the liver function tests (LFTs), although details on the biochemical response are not thoroughly reported.Table 1Cases of suspected AIH triggered by the vaccine reported in the literature.

ReferenceVaccinePatient’s characteristicsClinical presentation and laboratory dataTherapyOutcome
Age, genderAutoimmune comorbiditiesPrevious COVID-19 infectionOther comorbidities
Avci & Abasiyanik [15]mRNAPfizer/BioNTech,1 month before61, FHashimoto thyroiditisYes, mild, 8 months beforeHypertensionAcute icteric ANA, ASMA, hyper-IgG, fibrosis F2,Prednisolone + azathioprine add-on35 days follow-up, mild transaminases and bilirubin
Bril et al. [16]mRNAPfizer/BioNTech,7 days before35, FNot reportedNoGestational hypertension and cesarian section 3 months beforeAcute icteric, normal IgG, no fibrosisPrednisone 20 mg/day50 days follow-up, transaminases normalization
Cao et al. [17]Inactivated whole-virion SARS-CoV2 (Coronavac)57, FNot reportedNoNot reportedAcute icteric, pruritus IgG slight elevation, ANA+, Fibrosis F2Methylprednisolone, UDCA + azathioprine add-on5 months follow-up, no relapse
Clayton-Chubb et al. [23]ChAdOx1 nCoV-19 vaccine (Oxford-AstraZeneca), 26 days before36, MNoNoHypertension, laser eye surgery 2 weeks beforeAcute, sub-icteric, asymptomatic, ANA+, normal IgG, no fibrosisPrednisolone 60 mg/day24 days, normalization of bilirubin, marked reduction of ALT
Garrido et al. [24]mRNA Moderna, 2 weeks before65, FNoNoPolycythemia vera under PEG-IFNAcute icteric severe, ANA, hyper-IgG, no fibrosisPrednisolone 60 mg/day1 month, improvement of LFTs and IgG normalization
Ghielmetti et al. [25]mRNA-1273, 7 days before63, MNoNo, unknown but anti-cardiolipin+Type 2 diabetes, ischemic heart diseaseAcute icteric, hyper-IgG, ANA+, AMA+ (different from PBC) APCA+, no fibrosisPrednisone 40 mg/day, rapidly tapered14 days follow-up
Goulas et al. [26]mRNA Moderna, 2 weeks before52, FNoNoAcute icteric, ANA+, ASMA+, hyper-IgG, no fibrosis reportedPrednisolone 50 mg/day, azathioprine add-onUnknown
Londono et al. [27]mRNA Moderna, 7 days after the II dose41, FNot reportedNoHormonal therapy for premature ovarian failureAcute icteric, ANA, ASMA, anti-SLA/LC+, hyper-IgG, no fibrosisPrednisone 1 mg/KgNormalization of LFTs
Palla et al. [28]mRNAPfizer/BioNTech 1 month after II dose40, FSarcoidosisTransaminases 3–4 x ULN fluctuation, ANA+, hyper-IgG, active hepatitis, fibrosis with septaPrednisolone 40 mg/dayTransaminases decline after 7 days of prednisolone
Rela et al. [29]ChAdOx1 nCoV-19 vaccine (Oxford-AstraZeneca), 20 days before38, FNo (hypothyroidism?)NoHypothyroidismAcute icteric, ANA+, IgG mildly elevated, multiacinar hepatic necrosis, no fibrosisPrednisolone 30 mg/day and tapering after 4 weeks1 month of follow-up normal LFTs
ChAdOx1 nCoV-19 vaccine (Oxford-AstraZeneca), 16 days before62, M2 episodes of jaundice resolved with native medicationAcute severe AIH, autoantibodies negative, mild fibrosisPrednisolone 30 mg/day + plasma exchange 5 cyclesPersistent cholestasis → death in 21 days for economic constraints regarding liver transplantation
Rocco et al. [30]Pfizer/BioNTech 1 week before (II dose)89, FHashimoto thyroiditisNoPrevious acute glomerulonephritis, pravastatin and low-dose aspirin for primary preventionAcute icteric, ANA+, hyper-IgG, no fibrosisPrednisone 1 mg/Kg/day and tapering3 months of follow-up, progressive improvement
Tan et al. [31]mRNA Moderna, 6 weeks before56, FNot reportedNoRosuvastatinAcute icteric, ANA+, ASMA+, hyper-IgG, also eosinophil, early fibrosisBudesonide1 week of follow-up
Tun et al. [32]mRNA Moderna, 3 days before (I dose) and 2 days before (II dose)47, MNot reportedNoNot reportedAcute icteric, ANA+ hyper-IgG, rapidly resolved and then reappeared 2 days after the II dose, minimal fibrosisPrednisolone 40 mg/day2 weeks of follow-up PT normalized
Vuille-Lessard et al. [33]mRNA Moderna, 3 days before76, FHashimoto thyroiditisYes, 3 months before (mild disease)Prior urothelial carcinomaAcute icteric, hyper-IgG, ANA+, ASMA+, ANCA+, steatosis, active AIH, fibrosis not evaluablePrednisolone 40 mg/day + azathioprine add-on 2 weeks after4 months follow-up: LFTs normalization after 4 weeks, stop azathioprine and 6 weeks after no relapse
Suzuki Y et al. [34]mRNA Pfizer/BioNTech 10 days before (II dose)80, FNot reportedNot reportedGastroesophageal reflux esophagitisAcute icteric, ANA+, hyper-IgGPrednisone at an initial dose of 0.8 mg/kg/day, then tapered to 10 mg/week50 days of follow-up: transaminases normalization
mRNA Pfizer/BioNTech 4 days before (II dose)75, FNot reportedNot reportedDyslipidemiaAcute icteric, ANA+, AMA +, hyper-IgGPrednisone at an initial dose of 1 mg/kg/day, then tapered to 10 mg/week105 days of follow-up: transaminases normalization
mRNA Pfizer/BioNTech 7 days before (I dose)78, FPrimary biliary cholangitisNot reportedNoAcute, ANA+, AMA+, hyper IgGPrednisone at an initial dose of 0.6 mg/kg/day, then tapered to 10 mg/week103 days of follow-up: transaminases normalization
Torrente et al. [35]ChAdOx1 nCoV-19 vaccine (Oxford-AstraZeneca), 3 weeks before49, FHypothyroidism (?), ANA+NoHypothyroidism treated with levothyroxineAcute AIH, ANA+, hyper-IgG, no fibrosisPrednisone 30 mg/day then tapering and azathioprine add-onTransaminases decrease after 2 weeks
Rigamonti C et al. [36]mRNAPfizer/BioNTech, 7 patientsmRNA Moderna, 2 patientsChAdOx1 nCoV-19 vaccine (Oxford-AstraZeneca),3 patientsmedian age 62 years (range 32–80)6 F, 6 M3 thyroiditis,2 rheumatoid arthritis,1 systemic lupus erythematosus10 acute onset,8 jaundice,8 positive autoantibodies (6 ANA, 1 SMA, 1 LKM-1)Prednisone / prednisolone +/- azathioprinemedian follow-up 3 months: 58% complete biochemical response
Efe C et al. [37]mRNAPfizer/BioNTech, 1 patient53, MNoneNot reportedNoneAcute icteric hepatitis, no ANA, hyper-IgG, no fibrosisprednisolone (40 mg/day) and plasma exchangeLiver transplantation

Adverse effects of the vaccine are possible, and abnormal liver function tests following vaccination represent an important clinical issue. AIH is a relatively rare, chronic immune-mediated liver disease, which develops in genetically predisposed individuals following environmental triggers; viral infections and drug exposures have been suggested to trigger the disease, but not definitive evidence is available [[19],[20]]. AIH-like onset after vaccination – other than anti-SARS-CoV-2 – has been also previously reported [[21]]. However, even if it can be speculated that the vaccines can disturb self-tolerance and trigger autoimmune responses through cross-reactivity with host cells, it might be hard to definitively state that AIH is induced by a vaccine. Considering the reported AIH-like cases following SARS-CoV-2 vaccination, timing of occurrence of acute hepatitis from vaccination in some of them is very short (less than 7 days), suggesting that a dysregulation of immune system has already occurred before vaccination in those cases. So far, given the availability of only observational literature without a structured collection of AIH-like cases after anti-SARS-CoV-2 vaccines, no definitive conclusions can be drawn. There is a need for population-based studies to gather data on the incidence, severity, and clinical features of anti-SARS-Cov-2 vaccination-induced AIH under the umbrella of the national and European Scientific Societies.In the meantime, while intensive vaccination against SARS-CoV-2 continues, healthcare providers should include the diagnosis of AIH triggered by vaccines in the differential diagnosis in cases of acute hepatitis of unexplained etiology and manage them as drug-induced AIH or AIH-like liver injury as recommended by current guidelines [[22]].


*These recommendations will be reviewed periodically as further information becomes available.

  • •AIH patients should receive anti-SARS-CoV-2 vaccination consistent with the age restriction of the local approval. In Italy, as recommended by the Italian Ministry of Health for all immunosuppressed patients, mRNA vaccines should be used. Based on the data for the mRNA vaccines available, there is no preference for one vaccine over another.
  • Patients with AIH are suggested to undergo vaccination when the disease activity is controlled by immunosuppressive therapy. To date there are no data available to establish variations on the interval between doses of anti-SARS-Cov2 vaccine.
  • There is no current evidence to recommend suspension or reduction of immunosuppressive drugs in AIH patients before or immediately after anti-SARS-CoV-2 vaccination.
  • The risk of AIH flare or disease worsening following anti-SARS-Cov-2 vaccination has not been assessed to date and specific studies are required before defining a line of recommendation. Based on available data routine testing of transaminases levels in AIH patients after vaccination could be suggested in selected patients although the timing needs to be defined.
  • •Testing of antibody levels for IgM and/or IgG to spike or nucleocapsid proteins to assess immunity to SARS-Cov2 after vaccination in AIH patients is not recommended, nor to assess the need for vaccination in an unvaccinated AIH patients.
  • Patients with new acute onset of liver injury following anti-SARS-Cov-2 vaccine should be managed as suggested by current guidelines and known clinical algorithms, including the indication to liver biopsy. Considering the lack of evidence currently available to exclude drug induced AIH in this setting, immunosuppressive therapy should be carefully considered and used if AIH diagnosis is confirmed; long-term immunosuppressive therapy needs to be assessed on a patient-by-patient basis.
  • Patients with newly diagnosed AIH or AIH flare after anti-SARS-Cov-2 vaccine should be consider for vaccine booster; however, the timing of the booster could be personalised based on the disease activity and ongoing therapy and discussed case-by-case with an expert center in autoimmune liver diseases.
  • Given the limited number of cases compared to the number of vaccinated subjects, extended testing of transaminases level after vaccination in the general population is not sustainable nor suggested.
  • EMA’s PRAC encourages all healthcare professionals and patients to report any cases of autoimmune hepatitis and other adverse events in people after vaccination.

A Case of Hepatotoxicity After Receiving a COVID-19 Vaccine

Authors: Muath M. AlqarniAmmar Z. FaloudahAmjad S. AlsulaihebiHassan K. HalawaniAbdulmajeed S. Khan Published: December 16, 2021  DOI: 10.7759/cureus.20455


The coronavirus disease 2019 (COVID-19) has led to a global health crisis. Its clinical manifestations are well-documented, and severe complications among patients who survived the infection are being continuously reported. Several vaccines with well-established efficacies and excellent safety profiles have also been approved. To date, few side effects of vaccines have been reported. Drug-induced hepatotoxicity is an extremely rare side effect of these vaccines, with few reported instances. In this case report, we describe a patient who experienced hepatotoxicity after receiving the COVID-19 vaccine from Pfizer BioNTech.


The coronavirus disease 2019 (COVID-19) has caused an unprecedented global health crisis. Its most common symptoms include fever, cough, fatigue, and myalgia. Rarely, patients may develop an acute respiratory distress syndrome or multiple organ failure [1]. Other conditions, such as liver injury, may occur. Various factors can lead to liver injury, including severe inflammatory responses, severe hypoxia, drug-induced liver injury (DILI), and worsening of pre-existing metabolic conditions [2]. The manifestations of liver injury vary from elevated serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin to hepatic dysfunction in severe cases [3]. In May 2020, the Pfizer‐BioNTech COVID‐19 vaccine received emergency authorization for use among adolescents aged 12-15 years [4]. Clinical trials have demonstrated that its efficacy in this age group may be as high as 100%. The vaccine’s side effects are typically mild and non-life-threatening, including headache, fatigue, myalgias, and chills [5]. However, there have been reports on extremely rare yet life-threatening side effects, such as anaphylactic shock, deep venous thromboembolism, and pulmonary embolism [1,6].

Case Presentation

A 14-year-old female, not known to have any chronic illnesses, presented to the emergency department with epigastric pain, diarrhea, nausea, and vomiting for the past four days. Three days prior to her current presentation, the patient received the second dose of the Pfizer/BioNTech BNT162b2 mRNA COVID-19 vaccine. The patient denied the use of any pharmaceutical, herbal, or recreational drugs. Upon arrival to the emergency room, the patient had a temperature of 36.9°C, a pulse rate of 128 bpm, a blood pressure of 90/63 mmHg, a respiratory rate of 18 rpm, and oxygen saturation of 97% on room air. On physical examination, the patient was conscious, oriented, and had a Glasgow coma scale (GCS) score of 15/15. In addition, she had mild epigastric tenderness and jaundice. No signs of chronic liver disease were evident.

On the first day of admission, vital signs returned to normal after resuscitation with intravenous fluids. The patient’s urine was dark as observed after urinary catheter insertion. The hematology panel showed Leukopenia, neutropenia, and lymphopenia among others as seen in Table 1. Biochemical and coagulation profile workups are shown in Table 2. Abdominal ultrasound was unremarkable except for a minimal rim of free fluid in the pelvic cavity. Along with conservative treatment, the patient was started on N-acetylcysteine, lactulose, and Vitamin K. In addition, ceftriaxone was given as an empirical antibiotic. On the second day, the results of AST, ALT, and alkaline phosphatase decreased, yet remained abnormally high (Figures 12).

DateWhite blood cellsNeutrophilsLymphocytesPlateletsTotal bilirubinDirect bilirubin
09/08/20211.670.9 (53.9%)0.68 (40.7%)107121.186.1
10/08/20211.220.58 (47.6%)0.56 (45.9%)107117.981.1
11/08/20211.080.37 (34.3%)0.66 (61.1%)101156.694.3
12/08/20211.250.49(39.2%)0.69 (55.2%)101179.6106.8
13/08/20211.090.53(48.6%)0.53 (48.6%)86213.4122.2
14/08/20211.000.52 (52.0%)0.45 (45.0%)87231.6154.0
15/08/20211.380.72 (52.2%)0.60 (43.5%)83291.4187.5
Table 1: Trend of the complete blood counts and bilirubin

Normal ranges: White blood cells: 4-10 x 109/L, Neutrophils: 2-7×103/µL (40%-75%), Lymphocytes: 1-3.5×103/µL (20%-45%), Platelets: 150-400×103/µL, Total bilirubin: 0-21 µmol/L, Direct bilirubin: 0-3.4 µmol/L

DateProthrombin timeAPTTinternational normalized ratioPotassiumSodium  Ammonia  Creatine  
Table 2: Trends of the chemical and coagulation profiles

Abbreviations: APTT: Activated Partial prothrombin time, INR: international normalized ratio

Normal ranges: Prothrombin time: 11-13 seconds, Partial prothrombin time 28-40 seconds, INR: 0.9-1.2, Potassium: 3.5-5.1 mmol/L, Sodium: 136-145 mmol/L, Ammonia: 11-51 µmol/L

Figure 1: AST and ALT trends

Normal ranges: AST – Aspartate transaminase (0-40 U/L), ALT – Alanine transaminase (0-41 U/L)

Figure 2: Alkaline phosphatase and albumin trends

Normal ranges: Albumin: 39.7-49.4 mmol/L, Alkaline phosphate: 35-104 mmol/L

On the fourth day, the patient became agitated and non-responsive, when assessed, her GCS score dropped to 8/15. Consequently, she was transferred to the intensive care unit, where she was intubated. Consultations from gastroenterology, infectious disease, neurology, and hematology departments were requested. Following this, a wide range of infectious, immunological, and toxicological tests were ordered (Tables 3,4). Nevertheless, all the results were unremarkable. To rule out structural brain pathologies, a brain computed tomography without contrast was performed. A suspicious hypodense lesion in the right temporal lobe was identified. However, the findings from the brain magnetic resonance imaging were unremarkable.

Blood culture and sensitivity Negative
Cytomegalovirus immune globulin M (CMV IgM)Negative
Indirect Coombs testNegative
Direct Coombs testNegative
Hepatitis A virus immune globulin M (HAV IgM)Negative
Hepatitis C virus antibodies (enzyme immunoassays) Negative
Hepatitis B surface antigen (HBsAg)Negative
Urine culture and sensitivityNegative
human immunodeficiency virus serology (HIV)Negative
Stool Culture and sensitivityNegative
Chikungunya PCRNegative
Alkhurma virus PCRNegative
Dengue virus PCRNegative
Dengue virus serotypeNegative
Dengue virus IgGNegative
Dengue virus nonstructural protein 1 (NS1)Negative
Dengue virus IgMNegative
Rift valley fever PCRNegative
Anti-Smooth Muscle Antibody (ASMA)Negative
Antinuclear Antibodies (ANA)Negative
Anti-Liver-Kidney Microsomal Antibody (LKM)Negative
Table 3: Immunologic and infectious work-up for liver disease

Abbreviations: Ig: immunoglobulin, PCR: polymerase chain reaction

Name of the tested substanceResult
Salicylic acidNegative
Narcotic alkaloids and its derivativesNegative
Barbituric acidNegative
Tricyclic antidepressants Negative
Organophosphorus pesticidesNegative
Table 4: Urine and blood toxicology panel

The patient’s level of consciousness returned to normal by the seventh day, her liver enzyme levels continued to decline, and her symptoms have resolved. Afterward, she was transferred to a liver transplant center for further investigation and management.


DILI is the most common cause of acute liver injury in developed countries [7]. Its presentation ranges from an incidental elevation of liver enzymes to outright acute liver failure [8]. There are two types of DILI: idiosyncratic and intrinsic. The most common type of which is the intrinsic type that has a short latency period and is dose-dependent. An example of an offending agent in this type is acetaminophen. Contrarily, the idiosyncratic type is less common and has a longer latency. A few examples of idiosyncratic drugs are amoxicillin, nonsteroidal anti-inflammatory drugs, and isoniazid [9]. In our case, we hypothesized the type of DILI to be idiosyncratic, due to the short latency period.

The diagnosis of DILI is made by identifying a relationship between drug exposure and the onset of liver disease. It is important to exclude any infectious, autoimmune, or other forms of liver disease. A thorough medical history and a high clinical suspicion are the basis for a correct diagnosis. A recovery following withdrawal from an offending agent may indicate DILI [10]. A diagnostic criterion that can be utilized in diagnosing DILI is the Rousse Uclaf Causality Assessment Method of the Council of International Organization of Medical Science (RUCAM/CIOMS) [11]. This criterion was applied to our patient’s case, and a total of 6 was calculated, indicating that DILI is probable.

Currently, there is no effective treatment for DILI other than discontinuing the offending drug and providing patients with supportive measures until their condition improves [12]. The exception is acetaminophen intoxication in which an antidote can be used in management, namely N-acetylcysteine. Early transfer of patients with idiosyncratic DILI to tertiary liver centers is important. Liver transplantation increases overall survival from 27.8% to 66.2% [13]. Withholding the transplantation can result in infection, brain damage, organ failure, and even death [14].

There have been three reports of patients having hepatic failure, with one case being acute, after receiving the Pfizer/BioNTech BNT162b2 mRNA vaccine in the United Kingdom between September 12, 2020 and September 4, 2021. Moreover, there have been 17 reported cases of liver injury, with two cases being drug-induced [15]. The possible side effects of the COVID-19 vaccines on the liver are not limited to one type. Two case reports suggested that the ChAdOx1 nCoV-19 vaccine (Oxford-AstraZeneca) may trigger acute autoimmune hepatitis [16]. Mann et al. reported a case of a 61-year-old female who developed generalized weakness and low-grade fever after receiving the second dose of Pfizer/BioNTech BNT162b2 mRNA vaccine. The patient had an ALP of 207 µ/L, total bilirubin of 6.2 mg/dL, direct bilirubin of 3.9 mg/dL, a WBC of 17 x 109, and AST of 37 U/L. All laboratory workup and imaging to investigate possible etiologies were unremarkable. As compared to our case, there were significant differences in age group, initial presentation, and degree of liver injury [17].

Prior to her recent presentation, our patient had no chronic illnesses. Given that her history, physical examination, and laboratory workups were unremarkable, the patient’s clinical picture was attributed to hepatotoxicity secondary to the Pfizer/BioNTech BNT162b2 mRNA vaccine, the only pharmacological agent that she was exposed to before her current presentation.


This is a case of hepatotoxicity in a 14-year-old patient that occurred after receiving the second dose of the Pfizer/BioNTech BNT162b2 mRNA vaccine. The exhaustive clinical and laboratory evaluation failed to establish any other plausible etiology besides the vaccine. The purpose of this report is to raise awareness of this uncommon but potentially life-threatening side effect.


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Autoimmune hepatitis after SARS-CoV-2 vaccine: New-onset or flare-up?

Authors: Enver Avci 1Fatma Abasiyanik 2

Autoimmune 2021 Dec;125: 102745. doi: 10.1016/j.jaut.2021.102745  Epub 2021 Nov 11. PMID:  34781161PMCID: PMC8580815DOI: 10.1016/j.jaut.2021.102745


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been reported to trigger several autoimmune diseases. There are also recent reports of autoimmune diseases that develop after SARS-CoV-2 vaccines. Autoimmune hepatitis is a polygenic multifactorial disease, which is diagnosed using a scoring system. A 61-year-old woman presented with malaise, fatigue, loss of appetite, nausea and yellow eyes. She had a Pfizer/BioNTech BNT162b2 mRNA vaccine a month ago. Her physical examination revealed jaundice all over the body, especially in the sclera. The laboratory tests showed elevated liver enzymes and bilirubin levels. Antinuclear antibody and anti-smooth muscle antibody were positive and immunoglobulin G was markedly elevated. The liver biopsy revealed histopathological findings consistent with autoimmune hepatitis (AIH). The patient was diagnosed with AIH and initiated on steroid therapy. She rapidly responded to steroid therapy. A few cases of AIH have been reported after the COVID-19 vaccine so far. Although the exact cause of autoimmune reactions is unknown, an abnormal immune response and bystander activation induced by molecular mimicry is considered a potential mechanism, especially in susceptible individuals. As intensive vaccination against SARS-CoV-2 continues, we would like to emphasize that clinicians should be cautious and consider AIH in patients presenting with similar signs and symptoms.


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Acute hepatitis with autoimmune features after COVID-19 vaccine: coincidence or vaccine-induced phenomenon?

Authors: José M Pinazo-Bandera 1Alicia Hernández-Albújar 1Ana Isabel García-Salguero 2Isabel Arranz-Salas 2Raúl J Andrade 1 3Mercedes Robles-Díaz 1 3

Gastroenterol Rep (Oxf) 2022 Apr 27;10:goac014. doi: 10.1093/gastro/goac014. eCollection 2022.


Autoimmune diseases result from a breach of immunological self-tolerance and tissue damage by autoreactive T lymphocytes. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is characterized by an inflammatory dysregulation that has been associated with the development of autoimmune processes [1].

Molecular mimicry has been suggested as a potential mechanism for these associations as well as ‘bystander activation’ where the infection may lead to activation of antigen presenting cells that may activate autoreactive T-cells, with the production of pro-inflammatory mediators and tissue damage [1].

There is a potential antigenic cross-reactivity between SARS-CoV-2 and human tissue possibly linked to an increase in autoimmune diseases. A recent study showed that antibodies against the spike protein S1 of SARS-CoV-2 had high affinity against some human tissue proteins such as transglutaminase 2 and 3, or myelin basic protein, among others [2].

As both mRNA vaccine (Comirnaty BioNTech BNT162b2 and Spikevax ARNm-1273) and vectorial vaccine (ChAdOx1nCoV-19 Vaxzevria/Covishield) give rise to the production of protein S, the antibodies produced against this protein after vaccination may also trigger autoimmune conditions in predisposed individuals.

Thirteen case reports (including 16 patients) have recently reported an association between COVID-19 vaccines and acute hepatitis development [3–15].

Here we report two new cases of liver injury possibly related to COVID-19 vaccination.

Case 1

A 77-year-old woman developed intense malaise, vomiting and disorientation 2 days after receiving the second dose of Comirnaty vaccine and was hospitalized the following day. She did not have a history of autoimmune disorders. She denied alcohol drinking and was on long-term therapy with bromazepam, losartan, and omeprazole. Her previous liver tests back in 2020 were normal.

Physical examination was normal except for scleral icterus. Liver test showed acute hepatocellular injury: total bilirubin (TB) 3.1 mg/dL (reference, <1 mg/dL), aspartate aminotransferase (AST) 474 U/L (reference, <40 UI/L), alanine aminotransferase (ALT) 552 U/L (reference, <40 U/L), and alkaline phosphatase (ALP) 159 U/L (reference, <117 U/L). Immunoglobulin G levels were within normal ranges (reference, 800–1,600 mg/dL), while anti-nuclear antibody and anti-mitochondrial antibody M2 were detected with 1/160 and 1/40 titre, respectively. Human leukocyte antigen (HLA) testing was positive for HLA-DR4. All the other possible aetiologies were ruled out.

The patient was discharged and closely monitored. Due to increased transaminase levels, she underwent a liver biopsy (Supplementary Figure 1.1), which showed findings compatible with autoimmune hepatitis (AIH).

Prednisone 60 mg/day on tapering dose was initiated and 3 weeks later liver test had markedly improved. Azathioprine was added 2 months later, but it had to be withdrawn due to rash. Prednisone was then replaced by budesonide 9 mg/day. Five months after onset, transaminases were within the normal range; however, the subject was hospitalized with neurologic symptoms in relation to brain lesions in both hemispheres of probable infectious origin and died 1 month later.

Case 2

A 23-year-old man presented with mononucleosis syndrome-like symptoms and jaundice at the emergency room, 10 days after receiving the second dose of Spikevax vaccine. He did not suffer from previous autoimmune disorders. He denied having taken any conventional drug treatments as well as alcohol consumption.

Physical examination was unremarkable except for scleral icterus. Liver tests showed acute hepatocellular injury: TB 2.3 mg/dL, AST 702 U/L, ALT 587 U/L, and ALP 202 U/L. Immunoglobulin G levels were minimally elevated (1,647 mg/dL), while autoantibodies resulted as negative. HLA testing was positive for HLA-DR3. Serology ruled out viral causes and abdominal ultrasonography was normal. After admission to the hospital, a thoracic-abdominal scan was performed and revealed generalized lymphadenopathy.

He underwent a liver biopsy (Supplementary Figure 1.2), which showed findings compatible with AIH.

Prednisone 60 mg/day on tapering dose was initiated and 1 month later lymphadenopathies were undetectable and liver test had significantly improved. Three months after onset, transaminases were within the normal range and he is still on low-dose prednisone 10 mg/day.


These new cases of liver injury compatible with AIH, which developed post COVID-19 vaccination, along with 13 prior published case reports (16 patients) reinforce that this association could be more than coincidental. In the previously published case reports, all the patients, except three, were females and their age ranged from 35 to 80 years [3–15]. Twelve of these patients received one of the mRNA vaccines [35–121415], while four patients received vectorial vaccines [41213]. In 6 of the 16 patients, liver biopsy revealed infiltration with eosinophils [347914] and IgG levels were increased in 12 cases [4–1215].

Fourteen reported patients were successfully treated with prednisolone whereas two died due to acute liver failure [412] (Table 1).

Table 1.

Characteristics of patients with liver injury after SARS-CoV-2 vaccine (published cases and two new cases)

AuthorVaccineDoseDays until clinical onsetGenderAgeLiver-injury patternAutoimmune disease historyAuto- antibodiesIgGBiopsySteroid responseDeath
Compatible (Yes/No)Eosinophils infiltration (Yes/No)
Bril et al. [3Comirnaty BioNTech BNT162b2 1st 13 35 Hep None ANAAnti-dsDNA Normal Yes Yes Yes No 
Rela et al. [4(2 cases) ChAdOx1nCoV-19 Covishield (both patients) NA 20 38 NAa None ANA High Yes Yes Yes No 
NA 16 65 NAa None NA NA Yes Yes No Yes 
Rocco et al. [5Comirnaty BioNTech BNT162b2 2nd 80 Hep Hashimoto disease ANA High Yes No Yes No 
Londoño et al. [6Spikevax, ARNm-1273 2nd 41 Hep None ANASMASLALC-1 High Yes No Yes No 
Tan et al. [7Spikevax, ARNm-1273 1st 35 56 Hep None ANASMA High Yes Yes Yes No 
McShane et al. [8Spikevax, ARNm-1273 1st 71 Hep None SMA High Yes No Yes No 
Ghielmet-ti et al. [9Spikevax, ARNm-1273 1st 63 Hep None ASMAANCAANA High Yes Yes Yes No 
Garrido et al. [10Spikevax, ARNm-1273 1st 14 65 Hep None ANA High Yes No Yes No 
Avci et al. [11Comirnaty BioNTech BNT162b2 NA 14 61 Mix Hashimoto disease ANASMA High Yes No Yes No 
Erard et al. [12(3 cases) Spikevax, ARNm-1273(two first patients)ChAdOx1nCoV-19 Vaxzevria(third one) 2nd 10 80 NAa None Negative High Yes No Yes No 
1st 21 73 NAa None Negative High Yes No Yes No 
1st 20 68 NAa None Negative High Yes No No Yes 
Clayton-Chubb et al. [13ChAdOx1nCoV-19 Vaxzevria 1st 26 36 Hep None ANA Normal Yes No Yes No 
Lodato et al. [14Comirnaty BioNTech BNT162b2 1st 15 43 NAa None Negative Normal Yes Yes Yes No 
Vuille-Lessard et al. [15Spikevax, ARNm-1273 1st 76 Hep Hashimoto disease ANA High Yes No Yes No 
Pinazo et al. (2 cases) Comirnaty BioNTech BNT162b2(First one)Spikevax, ARNm-1273(second one) 2nd 77 Hep None ANAAMANegative Normal Yes Yes Yes Yesb 
2nd 10 23 Hep None High Yes No Yes No 

M, male; F, female; NA, not available; Hep, hepatocellular; Mix, mixed; IgG, immunoglobulin G; ANA, anti-nuclear antikor; SMA, smooth muscle antibodies; dsDNA, double-stranded DNA antibodies; LC1, liver sitozol antibody; anti-SLA, soluble liver antigen antibodies; ANCA, anti-neutrophil cytoplasmic antibodies; AMA, anti-mitochondrial antibodies.a

ALP (alkaline phosphatase) not available.b

The patient died due to an extrahepatic cause (brain lesions in both hemispheres of probable infectious origin).Open in new tab

In both cases of the present study, a number of laboratory (including HLA testing) and histological features supported the autoimmune nature of the liver injury. In our first case, the short period elapsed after vaccine administration, the laboratory and histopathological findings (showing moderate liver fibrosis), the positive HLA-DR4, and the response to therapy suggest unmasking of AIH by the vaccine. However, in our second case, the medical history negative for liver and autoimmune diseases, the short time interval after vaccination, the typical onset of symptoms to which was added generalized lymphadenopathy, the elevated immunoglobulin G levels, the positive HLA-DR3, histopathological findings with absence of liver fibrosis, and the response to therapy reinforce the hypothesis of SARS-CoV-2 vaccine as a trigger of an autoimmune liver injury debut. We realize that there are no pathognomonic (laboratory or histological) features of AIH, but the appropriate exclusion of viral and metabolic causes of liver injury makes the autoimmune mechanisms the more likely explanation for both cases.

Taking into account the large number of vaccinated subjects worldwide, the suspicion of vaccine-related AIH carries important clinical implications. It is unknown whether prolonged immunosuppression would be required in these cases or whether re-exposure to a new dose of COVID-19 vaccine might trigger fulminant liver injury. Nevertheless, the risk of receiving another dose must be balanced against the risk of contracting SARS-CoV-2 infection. In addition, it remains unclear whether patients who have developed liver injury after vaccination with one type of vaccine can receive other COVID-19 vaccine with a different mechanism of action.

Post COVID-19 vaccination, AIH has been rarely reported so far [3–15], which might be due to either minimal awareness of this disease or because patients without jaundice often do not seek medical attention. However, given the growing number of cases compatible with AIH reported after SARS-CoV-2 vaccination, regulators should consider the inclusion of this potential adverse event in the label of COVID-19 vaccines.

In conclusion, clinicians should be aware of the potential association between the vaccines and the onset of immune mediated disorders such as AIH. However, this rare complication should not discourage people from getting vaccinated.


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Liver injury following SARS-CoV-2 vaccination: A multicenter case series

Authors: Hersh Shroff,1,∗Sanjaya K. Satapathy,2James M. Crawford,3Nancy J. Todd,4 and Lisa B. VanWagner1 J Hepatol. 2022 Jan  10.1016/j.jhep.2021.07.024 PMCID: PMC8324396PMID:  34339763

In response to the COVID-19 pandemic, two novel mRNA-based vaccinations against the SARS-CoV-2 virus have been manufactured and distributed in an unprecedented fashion. In light of their rapid uptake, providers must remain vigilant in their monitoring of new adverse events. In early 2021, multiple providers, communicating on AST LICOP and AASLD online forums, shared strikingly similar experiences with patients who presented with liver injury following COVID-19 vaccination with no other clear precipitants. Given the pattern, we report herein on a multicenter cohort of patients with liver injury following COVID-19 vaccination. No personally identifiable information or protected health information was collected for any patient. The series was reviewed by the Northwestern University IRB and deemed not to be human subjects research.

Our cohort includes 16 total patients (Table 1 ) aged 25 to 74, who presented between 5 to 46 days following their first vaccine dose (Pfizer: 12, Moderna: 4). Notably, 75% of patients (12/16) presented after their second vaccine dose.

Table 1

Patient characteristics.

CaseAge, sexLiver disease historyTiming of presentation (days)aPattern of injuryPeak lab valuesRelevant work-up (medications, labs, imaging)Biopsy findingscTreatmentRecovery status
ALT (U/L)ALP (U/L)Bili (mg/dl)INR (ratio)Inflammation severityd, locationCellular pattern of inflammationCholestasisd and bile duct featuresFibrosis
Pfizer vaccine
146, MNAFLD, prior
DILI (due to amoxicillin)
10Hep5941973.91.3ASMA 1:40
Other autoimmune and viral serologies negative
ERCP with new severe sclerosing cholangitis
No interface hepatitis
Mixed infiltrate+
Mild ductular proliferation
Focal portal and peri-portalEndoscopic biliary dilationRecovering
261, FNone34Hep2,3311603.71.3Received nitrofurantoin 3 months prior
ASMA 1:160, other autoimmune and viral serologies negative
Portal and lobular
No interface hepatitis
Lymphocytes and plasma cellsNone
Normal bile ducts
NoneOral prednisoneRecovering
361, MNone31Hep7652302.61.2Ibuprofen x 3 days
Autoimmune and viral serologies negative
Portal and lobular
No interface hepatitis
Normal bile ducts
NoneNoneFully recovered
471, MHCV (treated);
Compensated cirrhosis
27Chol1013671.7UnkNone performedNo biopsy performedNoneRecovering
574, FExtramedullary hematopoiesis of unknown significance on prior liver biopsy27Hep1,7793911.11.0ANA 1:640, other autoimmune serologies negative
Viral serologies negative
No biopsy performedNoneFully recovered
673, MAIH (treated)b6Hep8131140.7UnkNone performedNo biopsy performedOral prednisoneRecovering
725, FNone24Hep6354652.81.0Ibuprofen x 2 days
ANA 1:640, ASMA 1:20; viral studies negative
No biopsy performedNoneRecovering
861, FNone42Hep1,7352871.51.1ANA 1:320, other autoimmune serologies negative
EBV viral load 78, VZV IgM+/IgG+
Hepatic steatosis on imaging
No interface hepatitis
Mixed infiltrateNone
Neutrophilic peri-cholangitis
NoneOral prednisoneRecovering
937, FNone29Hep>5,0001442.85.5Autoimmune and viral serologies negativeNo biopsy performedNAC infusionFully recovered
1033, FAIH (treated)b
Compensated cirrhosis
Portal and lobular with interface hepatitis
Lymphocytes and plasma cellsNone
Normal bile ducts
CirrhosisOral prednisoneFully recovered
1168, MAIH (treated)b
Compensated cirrhosis
19Hep245550.91.1Imaging with new diagnosis of solitary HCC++
Portal and lobular with interface hepatitis
Mixed with plasma cellsNone
Normal bile ducts
CirrhosisOral prednisoneRecovering
1270, FPrior biliary stricture after cholecystectomy41Mixed961400.5UnkNoneNo biopsy performedNoneRecovering
Moderna vaccine
1366, FAIH (treated)b5Hep1,1993525.91.1Received shingles vaccine 3 months earlier
Viral serologies negative
Portal and lobular with interface hepatitis and central perivenulitis
Plasma cellsNone
Normal bile ducts
NoneOral prednisoneRecovering
1468, FNone15Hep2,367176252.2Autoimmune and viral serologies negative
E. Coli UTI treated with ceftriaxone (after ALI onset)
Portal and lobular
Interface hepatitis not reported
Severe bile ductular reaction
NoneIV steroids,
NAC infusion
1559, FNone31Hep86936714.72.4Tylenol several days per week for preceding year
ANA 1:640, IgG 1,750 other autoimmune serologies negative
Other viral markers negative
Portal and lobular
No interface hepatitis
Ductular reaction
NoneIV steroidsRecovering
1665, MNone46Mixed2,6642,52222.31.2Taking Tylenol/Norco for 4 days prior to presentation due to recent knee surgery
ANA 1:1,240, ASMA 1:40, IgG normal
Viral serologies negative
No interface hepatitis
Occasional bile duct injury

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AIH, autoimmune hepatitis; ALI, acute liver injury; ALP, alkaline phosphatase; ALT, alanine aminotransferase; ANA, anti-nuclear antibodies; ASMA, anti-smooth muscle antibodies; Bili, bilirubin; DILI, drug-induced liver injury; EBV, Epstein-Barr virus; HCC, hepatocellular carcinoma; INR, international normalized ratio; NAC, N-acetylcysteine; NAFLD, non-alcoholic fatty liver disease; UTI, urinary tract infection; VCA, viral capsid antigen.aIn relation to first dose of vaccine.bNo medication changes for over 6 months with normal preceding labs.cBiopsy findings are reported based on each institution’s written report. Biopsies were not independently reviewed.dSeverity of inflammatory infiltrate and cholestasis graded as follows: +, minimal or mild; ++, moderate; +++, severe/extensive.

Six patients had a history of chronic liver disease, including 4 (#6, 10, 11, 13) with autoimmune hepatitis (AIH) in treated remission (i.e., no medication changes or abnormal labs for a minimum of 6 months). Three patients had cirrhosis: 2 patients with AIH (#10 and 11) and 1 with previously treated HCV (#4).

The majority (13/16) of cases demonstrated a hepatocellular pattern of liver injury (peak alanine aminotransferase: 96 to >5,000 U/L). Of the remaining 3 cases, 1 (#4) was cholestatic and 2 (#12, 16) were mixed. Acute liver injury (ALI, defined as international normalized ratio [INR] >1.5) occurred in 3 patients (#9, 14, and 15; INR range 2.2 to 5.5); no patients developed acute liver failure.

Patient #1 was diagnosed with “new” sclerosing cholangitis via endoscopic retrograde cholangiopancreatography on this presentation; however, on chart review, he presented with drug-induced liver injury (DILI) (amoxicillin) two years earlier, at which time a magnetic resonance cholangiopancreatography showed subtle non-diagnostic biliary findings, raising the possibility of undiagnosed primary sclerosing cholangitis. At the time of presentation, the DILI was long-since resolved, and the current presentation appears to represent an ALI event in a patient with pre-existing cholangitis. Patient #2 had been prescribed a 3-day course of nitrofurantoin approximately 90 days prior to presentation. The scenario was deemed atypical for nitrofurantoin toxicity (particularly the short exposure and clinical presentation). Patients #3 and #7 used ibuprofen immediately following the second vaccine dose (2 to 3 days total, unknown total doses); patient #15 reported chronic acetaminophen use (3-4 grams for several days per week over the preceding year); and patient #16 had knee surgery 3 days prior to presentation and used alternating acetaminophen and acetaminophen-hydrocodone for a total of 4 days. None of these were deemed likely to be causative given the time frame and short exposures. No patient displayed laboratory evidence of viral hepatitis, and all patients tested negative for COVID-19 infection. While 7 of the 12 patients without previously known AIH had at least 1 positive autoimmune marker at the time of presentation, only 1 (#15) met IAIHG simplified criteria for “probable” AIH (anti-nuclear antibody 1:640, elevated IgG to 1,750 mg/dl, and biopsy “compatible” with AIH).1

Out of 16 patients, 10 underwent liver biopsy (Table 1). All exhibited portal inflammation (60% graded as moderate or severe). Five cases demonstrated a significant plasma cell component (of whom #10, 11, and 13 had pre-existing AIH and displayed interface activity), all of whom received prednisone. Cholestasis and bile duct reaction, though variably present, were only prominent in 1 case (#16) with severe cholestasis and minimal inflammation. Excluding patients with known cirrhosis (n = 3), significant fibrosis was not seen in any patient.

Out of 16 patients, 10 required hospitalization. In total, 6 of 16 patients required no treatment. Of the 10 who received treatment, 2 (#9, 14; both with ALI) received N-acetylcysteine infusions, and 8 (see Table 1) received steroids. Patient #1, newly diagnosed with sclerosing cholangitis, underwent biliary dilatation. Importantly, all patients recovered or were recovering from the acute event at the time of assembling our cohort.

We acknowledge that our series of patients with hepatic injury following mRNA-based COVID-19 vaccination contains retrospective and observational data without adjudication. Thus, our report is not structured to evaluate potential causality. In our patients with prior drug exposure (amoxicillin; nitrofurantoin; non-steroidal anti-inflammatory drugs, acetaminophen), the exposures were either too short or the presentations highly atypical (by laboratory data or histopathology) to be attributed solely to the medication. Thus, DILI is not readily implicated in this patient series, although it cannot be wholly excluded. We also consider unlikely direct hepatotoxicity from SARS-CoV-2 mRNA vaccines, noting the strong safety profile for delivery of lipid nanoparticle mRNA vaccines to human tissues.2 Rather, vaccine-induced immune-mediated hepatitis is a known phenomenon,3 , 4 and other autoimmune events (e.g., AIH, ITP) have been reported following COVID-19 vaccination.5 , 6 It is plausible that a similar mechanism is occurring here, whereby the host immune response directed against the COVID-19 spike protein triggers an aberrant, autoimmune-like hepatic condition in predisposed individuals. Many questions still remain. In particular, should patients at higher risk of hepatic autoimmunity (e.g., existing AIH, post-liver transplant) undergo pre-emptive laboratory monitoring post-vaccination? Will there be safety concerns for these patients if booster doses are recommended in the future?

We emphasize that our intent is not to promote vaccine hesitancy. The overwhelming benefits of these and other highly efficacious vaccines in the setting of a global pandemic greatly surpass any potential risk of liver injury that may exist. We simply aim to share a clinical scenario that has been observed independently by multiple providers at various institutions, with the hope that as vaccine uptake continues to increase, our shared experience can help in early recognition, further study, and management of potential adverse events.Go to:

Financial support

L.V.W. is supported by the National Heart, Lung and Blood Institute grant K23HL136891.Go to:

Authors’ contributions

Hersh Shroff (conceptualization, methodology, visualization, writing original draft, writing review and editing). Sanjaya K. Satapathy (visualization, resources, writing review and editing). James M. Crawford (visualization, resources, writing review and editing). Nancy J. Todd (resources, writing review and editing). Lisa B. VanWagner (conceptualization, methodology, resources, supervision, visualization, writing review and editing).Go to:

Data availability statement

Data and study materials will not be made available to other researchers.Go to:

Conflict of interest

The authors disclose no conflicts of interest.

Please refer to the accompanying ICMJE disclosure forms for further details.Go to:


We acknowledge the following individuals for assistance in contributing cases and reviewing the manuscript: Juan Pablo Arab (Pontificia Universidad Católica de Chile); Timea Csak (Northwell Health), Winston Dunn and Beth Floyd (University of Kansas); R. Todd Frederick (California Pacific Medical Center); Alexander Lemmer (Piedmont Healthcare); Benedict Maliakkal (Ascension Medical Group); Atoosa Rabiee (Washington DC VA Medical Center); and Priyanka Singh (Northwell Health).Go to:


Author names in bold designate shared co-first authorship

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jhep.2021.07.024.Go to:

Supplementary data

The following is the supplementary data to this article:Multimedia component 1:Click here to view.(1.4M, pdf)Go to:


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Safety and Immunogenicity of SARS-CoV-2 Vaccines in Patients With Chronic Liver Diseases (CHESS-NMCID 2101): A Multicenter Study

Authors: Jingwen Ai 1Jitao Wang 2Dengxiang Liu 3Huiling Xiang 4Ying Guo 5Jet.al.


Background & aims: We aimed to assess the safety and immunogenicity of inactivated whole-virion severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines in patients with chronic liver diseases (CLD) in this study.

Methods: This was a prospective, multi-center, open-label study. Participants aged over 18 years with confirmed CLD and healthy volunteers were enrolled. All participants received 2 doses of inactivated whole-virion SARS-CoV-2 vaccines. Adverse reactions were recorded within 14 days after any dose of SARS-CoV-2 vaccine, laboratory testing results were collected after the second dose, and serum samples of enrolled subjects were collected and tested for SARS-CoV-2 neutralizing antibodies at least 14 days after the second dose.

Results: A total of 581 participants (437 patients with CLD and 144 healthy volunteers) were enrolled from 15 sites in China. Most adverse reactions were mild and transient, and injection site pain (n = 36; 8.2%) was the most frequently reported adverse event. Three participants had grade 3 aminopherase elevation (defined as alanine aminopherase >5 upper limits of normal) after the second dose of inactivated whole-virion SARS-CoV-2 vaccination, and only 1 of them was judged as severe adverse event potentially related to SARS-CoV-2 vaccination. The positive rates of SARS-CoV-2 neutralizing antibodies were 76.8% in the noncirrhotic CLD group, 78.9% in the compensated cirrhotic group, 76.7% in the decompensated cirrhotic group (P = .894 among CLD subgroups), and 90.3% in healthy controls (P = .008 vs CLD group).

Conclusion: Inactivated whole-virion SARS-CoV-2 vaccines are safe in patients with CLD. Patients with CLD had lower immunologic response to SARS-CoV-2 vaccines than healthy population. The immunogenicity is similarly low in noncirrhotic CLD, compensated cirrhosis, and decompensated cirrhosis.


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