Abstract Introduction COVID-19-associated cholangiopathy is an emerging entity characterized by bile duct injury and cholestasis, predominantly in patients with severe or prolonged infection. Solid organ transplant recipients are particularly susceptible due to chronic immunosuppression and altered hepatic microcirculation. This case highlights progressive COVID-19 cholangiopathy culminating in hepatic duct necrosis and death of a bilateral lung transplant recipient. Case Description A 68-year-old man with bilateral lung transplantation in 2019 for idiopathic pulmonary fibrosis was admitted in November 2023 with COVID-19 pneumonia and acute hypoxemic respiratory failure requiring intubation (Figure 1). His post-transplant regimen included tacrolimus, mycophenolate, and prednisone, with infection prophylaxis using trimethoprim-sulfamethoxazole, isavuconazole, acyclovir, and letermovir. His hospital course was prolonged and complicated by bone marrow suppression, renal failure requiring dialysis, and persistent cholestasis. Imaging and endoscopic retrograde cholangiopancreatography (ERCP) confirmed cholangitis. Despite antimicrobial therapy and biliary drainage, bilirubin and alkaline phosphatase levels continued to rise. Repeat ERCP demonstrated hepatic duct necrosis, beaded intrahepatic bile ducts, and common bile duct dilation consistent with sclerosing cholangitis. A biliary drain was placed, but the patient subsequently developed Enterococcus bacteremia and progressive multi-organ failure. He died four months after the initial COVID-19 diagnosis. Discussion This case underscores COVID-19 cholangiopathy as a devastating post-infectious complication in immunosuppressed lung transplant recipients. The pathogenesis likely involves both direct viral cytopathic effects and immune-mediated endothelial injury to the biliary epithelium, compounded by ischemia during critical illness. Persistent cholestasis and biliary necrosis can progress despite drainage and supportive therapy. Furthermore, hepatic injury alters metabolism of calcineurin inhibitors, increasing risk for both toxicity and under-immunosuppression. Management remains largely supportive, emphasizing infection control, judicious immunosuppression adjustment, and early hepatology involvement. Recognition of COVID-19-related cholangiopathy is essential in transplant recipients with unexplained cholestasis, as progression can be rapid and fatal. This abstract is funded by: None
Greve et al. (Fri,) studied this question.