key: cord-339381-vvh06d2c authors: Han, Deheng; Fang, Qiang; Wang, Xingxiang title: SARS‐CoV‐2 was found in the bile juice from a patient with severe COVID‐19 date: 2020-06-12 journal: J Med Virol DOI: 10.1002/jmv.26169 sha: doc_id: 339381 cord_uid: vvh06d2c SARS‐CoV‐2 has infected over 170,000 people worldwide and was associated with substantial mortality. Previous studies have reported that the SARS‐CoV‐2 could be detected in sputum, faeces, urine and other specimens from COVID‐19 patients. In the case report, the novel coronavirus was found in the bile specimen from a patient with severe COVID‐19 by real‐time fluorescent RT‐PCR. In addition, much higher viral load in the bile juice than in the sputum indicated that a false positive error in the specimen was hardly possible. As far as we know, it is the first report about SARS‐CoV‐2 in the bile juice. We would love to share the information to other researchers. The report may have a significant impact on the clinical management and public health decision making. This article is protected by copyright. All rights reserved. SARS-CoV-2 was found in the bile juice from a patient with severe COVID-19 Coronavirus disease 2019 (Covid-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread to 163 countries/areas since December 2019. As of Mar 17, 2020, it has infected over 170, 000 people and resulted in death toll 7,904 over the world [1, 2] .The symptoms of SARS-CoV-2 infection vary widely, Mild cases were self-limited, and even didn't have clinical symptoms, but severe cases progressed rapidly, and would die from acute respiratory distress syndrome and multisystem organ failure. Previous studies have reported that the SARS-CoV-2 could be detected in sputum, faeces, tears, urine and other specimens of infected patients [3, 4] . In the case report, the novel coronavirus was found in the bile specimen from a patient with severe Covid-19. On January 28, 2020, a 59-year-old This article is protected by copyright. All rights reserved. Although he had been receiving artificial liver support system treatment during this hospitalization period, the serum level of bilirubin continued to rise significantly, and the maximum levels of total bilirubin and direct bilirubin were 476.7 and 437.9 μmmol/L, respectively. By asking the medical history, doctors learned that this patient had a history of undergoing liver transplantation two years prior and received an implantation of four plastic biliary stents. In view of the patient's medical history, the attending doctor considered bile duct obstruction as one of the reasons for liver function failure. So on day 23 after admission, the patient received endoscopic This article is protected by copyright. All rights reserved. retrograde cholangiopancreatography treatment. During the operation, doctors found that the biliary sludge was completely obstructed at the duodenal papilla, so they removed the biliary stents with a medical snare and performed endoscopic naso-biliary drainage treatment. On the following day, 60 mL of yellow-green bile was irrigated into a closed drainage bag (to avoid contamination) from a nasobiliary duct. The bile specimen later tested positive on real-time fluorescent reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2, and the cycle threshold value were 23 in the bile specimen and 32 in the sputum specimen which was collected on the same day, which means that much higher viral load in the bile juice than in the sputum. The potential causes of bile duct obstruction were as follows: 1. The primary disease and stent occlusion was the primary cause of bile duct obstruction. SARS-CoV-2 can injure cholangiocytes, and cause cholestasis [5] . 3. During the course, the patient had been treated with antipyretic agents and antiviral drugs. Including acetaminophen, oseltamivir, abidol or lopinavir, which may injure bile duct and cause cholestasis [6] . And there may more potential causes of bile duct obstruction, such as clotting effects of SARS-CoV-2, and this needs further investigation. To our knowledge, this is the first case in which bile juice SARS-CoV-2 was detected. It is known that bile juice is secreted by liver cells and biliary tract cells, which promote the digestion of fat and absorption of fat-soluble vitamins. Therefore, it is suggested that the hepatocytes and/or biliary tract This article is protected by copyright. All rights reserved. cells were infected by SARS-CoV-2 in the patient. And we speculate that SARS-CoV-2 detected in fecal specimens may, at least partly, originate from bile juice. Unfortunately, we did not know whether the SARS-CoV-2 in the bile juice survived or was contagious. Nothing to report A1 A2 A3 Figure A B: the lung CT imaging of the patient Figure A1 ,A2,A3 are represent the lung CT preformed at Day1 of illness, Figure B1 ,B2,B3 are represent the lung CT preformed at Day6 of illness, it is obvious that chest CT showed progressive infiltrate in both lungs, so he was transferred to the ICU and received invasive ventilator support. Figure C1 ,C2,C3 represent the total bilirubin, direct bilirubin, indirect bilirubin of the patient during the stay of hospital. Despite the medication and artificial liver therapy, there was no significant decline in the levels of serum bilirubin while hospitalized, combining the patient's medical history, the attending doctor considered common bile duct of the patient obstruction was one of the reasons, and patient was given a endoscopic retrograde cholangiopancreatography (ERCP) treatment in February 24, then the levels of serum bilirubin dropped. A novel coronavirus from patients with pneumonia in China A new coronavirus associated with human respiratory disease in China First case of 2019 novel coronavirus in the United States Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection Pulmonary Arterial Thrombosis in COVID-19 With Fatal Outcome: Results From a Prospective, Single-Center COVID-19 and Liver Dysfunction: Current Insights and Emergent Therapeutic Strategies