S2449 A Rare Case of Acute Liver Failure in Suspected Catastrophic Antiphospholipid Syndrome

INTRODUCTION: Catastrophic antiphospholipid syndrome (CAPS) is a rare syndrome which presents as system wide thrombotic events that leads to eventual multi organ failure Acute liver failure is less commonly seen in patients with CAPS We present a rare case of a 48 year old female with suspected CAPS who developed acute liver failure This patient tested positive for COVID-19 infection, which likely triggered CAPS CASE DESCRIPTION/METHODS: A 48 year old female with a history of CAD and hypertension presented to the hospital after being found by her husband at home to be unresponsive She reported a 1 week history of decreased appetite, nausea and vomiting Labs on admission were significant for: PT 13 9s, BUN 23, Cr 2 16, TB 12 6, DB 9 59, ALP 321, ALT 2480, AST 3320 Labs three months prior to admission were normal Hepatitis A and B, EBV serologies, ANA, ASMA, total IgG/IgM levels were negative Liver doppler was negative for thrombosis COVID-19 RT-PCR was positive Her hospital course was complicated by multi organ failure as well as coagulopathy Arterial doppler of the lower extremities showed an occluded right sided anterior tibial artery Lupus anticoagulant (LA) antibody was negative however a PTT-LA antibody was positive Liver biopsy showed extensive non-inflammatory centrilobular necrosis, patchy portal based mononuclear infiltrates suggestive of ischemic or toxic mediated injury secondary to drug or viral infection Subsequently, she went into acute renal failure requiring hemodialysis and respiratory failure requiring intubation Given the above findings, she was diagnosed with suspected CAPS DISCUSSION: CAPS is diagnosed in patients with sudden onset of multiorgan failure with presence of at least one venous, arterial or small vessel thrombosis in any organ with a positive antibody (ie LA, anti- cardiolipin or anti-beta glycoprotein I antibody) PTT-LA antibody has been reported to be a weak reagent for the LA antibody A positive PTT-LA antibody can imply that symptoms are due to a partial presence of the LA antibody We found no other cause for her multiorgan failure and given above findings, she was diagnosed with probable CAPS Although COVID-19 has been shown to cause elevation of liver enzymes in the literature, the degree of liver enzyme elevation as seen in our patient has not been reported