الفهرس 
COVID-19 INFECTIONOnly 14 pages are availabe for public view
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Abstract
T
he novel coronavirus first detected in Wuhan, China, in December 2019, named sever acute respiratory syndrome-2 (SARS-COV-2), causes coronavirus disease 2019 (COVID-19). COVID-19 is primarily transmitted through contact with droplets which contain viral particles.
A strong immune response was triggered in the lungs by the rapid replication of SARS-CoV-2. Cytokine storm give rise to acute respiratory distress syndrome and respiratory failure, that was considered one of the main causes of death in COVID-19 patients. In some COVID-19 cases, multiple organ failure had also been reported. Increasing levels of ALT, AST, and bilirubin in SARS-CoV-2 infection, indicating injury to the hepatic tissue. Some of these liver serum enzymes indicating hepatic damage, Albumin level was significantly decreased, indicating the severity of the infection. Gamma glutamyl transferase (GGT) elevated levels were reported only in patients with severe cases. On the contrary, there were unchanged levels of the alkaline phosphatase (AKP) irrespective of the severity of the infection. SARS-CoV-2 entry into the host cell is through the ACE2 receptor. Moreover, the type 2 cells in the lungs, the bile duct cells in addition to hepatocytes express ACE2, which could be the reason which causes liver injury during SARS-CoV-2 infection. The bile duct epithelial cells were included in immune responses and hepatocytes regeneration. Moreover, possessing a high number of ACE2 receptor on its surface, bile duct cells were more vulnerable to the SARS-CoV-2 infection resulting in hepatic injury, indicating that the hepatocytes were not directly involved in the liver injury. The liver damage degree is directly proportional to the SARS-CoV-2 infection severity.
It was reported that, there was suppression in COVID-19 patients` immunity in the early stage of the disease particularly T-cell mediated immunity. Furthermore, drugs used in COVID‐19 treatment might also act a major role in altering immune responses by means of regulating intracellular signaling pathways, hence prompting the reactivation process of EBV. High dose of corticosteroids which was used in COVID-19 treatment, had been stated as a risk factor for herpes virus reactivation, particularly EBV and CMV.
This study aimed to measure rate of prevalence of this coinfection in Egyptian COVID-19 participants with elevated liver enzymes and its relation to the severity and the outcome of COVID-19 infection in those patients.
This study included 110 patients with COVID-19 illness, 5 (4.5%) were Epstein-Barr virus seropositive and 5 (4.5%) were Human cytomegalovirus seropositive. Regarding the symptoms, the incidence of fever in the EBV & CMV seropositive group was apparently higher than that in the EBV & CMV seronegative group. In lab tests, the platelets and albumin of EBV & CMV seropositive group decreased more significantly than EBV & HCMV seronegative group, and serum ferritin, D-dimer and c-reactive protein show higher values in seropositive group than in seronegative group but not statistically significant. Seropositive group had received higher doses of steroids than seronegative group. The median of hospital stay in seropositive group was (15 days) nearly double that of seronegative group with statistically significant difference between both groups.
LIMITATIONS
S
ome limitations of this study should be acknowledged. Firstly, small sample size included to measure the prevalence of EBV and CMV coinfection in COVID-19 patients with elevated liver enzymes. Secondly, the study depends only on serological tests to detect either recent infection or reactivation of EBV and CMV in COVID-19 patients, rather than confirmation by Rt-PCR. thirdly, exclusion of pre-existing liver diseases was only by history. Finally, further studies in larger cohorts and in different populations are needed to confirm the findings of this study.
CONCLUSION
T
he current study concluded that the Coinfection of EBV and CMV in Egyptian COVID-19 patients has no effect on the disease severity or the clinical outcome of the disease.
There is higher hospital stay in EBV and CMV seropositive COVID-19 patients compared to seronegative group.
RECOMMENDATIONS
• Further studies are needed to confirm the findings of this study and to investigate the potential impact of EBV and CMV coinfection on COVID-19 outcomes in larger cohorts and in different populations.
• Clinicians should be aware of the possibility of EBV and CMV reactivation in COVID-19 patients with elevated liver enzymes, particularly those who receive high doses of corticosteroids.