Secondary Sclerosing Cholangitis (SSC): An Underrecognized Complication of Severe COVID-19 Pneumonitis

COVID-19-secondary sclerosing cholangitis (COVID-SSC) is a distinct subset of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) that presents after COVID-19 infection with alkaline phosphatase predominant elevation of liver enzymes. COVID-SSC typically presents within three months of COVID-19 diagnosis and most commonly occurs following severe COVID-19 infection. COVID-SSC can have different clinical degrees of severity, ranging from clinically latent, as shown in this case report, to severely symptomatic, requiring a liver transplant or leading to patient death.  We present a case of COVID-SSC that presented in an asymptomatic patient months after severe COVID pneumonitis requiring prolonged intubation who was initially misdiagnosed with autoimmune hepatitis and found to have early cirrhosis at the time of diagnosis. The case presented was initially clinically silent and overlooked for months. In the aftermath of severe COVID-19 infection, COVID-SSC should be included in the differential diagnosis of unclear cholestasis, and general practitioners should have a high index of suspicion when encountering disproportionate elevation of alkaline phosphatase in patients with a history of COVID-19, in particular, those requiring intensive care unit (ICU) level cares.