Pediatric Acute Liver Failure Due to Type 2 Autoimmune Hepatitis Associated With SARS‐CoV‐2 Infection

Although elevated liver enzymes are common in hospitalized children with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection, pediatric acute liver failure is an uncommon manifestation of COVID‐19 disease. We describe the case of a 3‐year‐old previously healthy female who developed acute liver failure secondary to type 2 autoimmune hepatitis preceded by mild infection with SARS‐CoV‐2. Testing for viral hepatitis was negative, and the patient did not meet diagnostic criteria for multisystem inflammatory disease in children (MIS‐C). A liver biopsy showed acute submassive hepatocyte necrosis with brisk CD3+ T lymphocyte infiltration and no evidence of fibrosis or chronic liver disease. Treatment with high‐dose methylprednisolone resulted in rapid normalization of alanine aminotransferase (ALT), aspartate aminotransferase (AST), international normalized ratio (INR), and ammonia levels, and liver transplantation was avoided. This case highlights a possible association between SARS‐CoV‐2 infection and subsequent development of autoimmune liver disease presenting with acute liver failure.