ACUTE LIVER FAILURE IN A 61-YEAR-OLD MAN. 11/29/18 Muhammad Ahmed, MD

Transcription

1 ACUTE LIVER FAILURE IN A 61-YEAR-OLD MAN 11/29/18 Muhammad Ahmed, MD

2 H&P 61-year-old male with a history of chronic ethanol use (4-6 beers/day x decades), hypertension, and a family history of hemochromatosis who was transferred from an outside hospital for management of acute liver failure. A liver biopsy was performed prior to transfer. The patient arrived severely confused. A fever of up to 103 F was noted during the patient s stay at the previous hospital. Vital signs: T 97 F, P 126, RR 26, BP 97/43, SpO2 100% on 2L/NC Laboratory results prior to transfer: ALT/AST 2043/5303, ammonia 61, LDH 6520, INR 1.37, PT/PTT 14/47.8

3 H&P (continued) Gen: mild agitation, frequently calling for help HEENT: dry oral mucosa without petechiae or mucosal lesions, no sublingual jaundice or icteric sclera CV: irregularly irregular, no mrg Resp: tachypneic, no distress, lungs clear bilaterally Abd: tender to palpation in RUQ, liver edge felt 1-2cm below rib line, no rebound, no guarding, normoactive bowel sounds, no splenomegaly Ext: warm, well perfused, no edema Neuro: follows directions, recognizes his family members, but asking nonsensical questions. No focal deficits Skin: no jaundice, small erythematous patch on medial right arm. No other evidence of rash

4 Differential Diagnosis for Acute Liver Failure Drugs (Acetaminophen overdose (most common cause in the Western World), etc) Infectious (Hepatotropic viruses (A, E, B etc (most common cause in the developing world), etc) Hyperthermic injury 2/2 heat shock or prolonged seizures Toxic insults (Amanita spp, etc) Metabolic disorders (Wilson s disease, etc)

5 Differential Diagnosis for Acute Liver Failure (continued) Immunologic insults (Autoimmune hepatitis, etc) Systemic hypotension (Sepsis, cardiogenic shock, etc) Budd-Chiari Syndrome

6 H&P (continued) Extensive infectious disease workup including Babesia, Lyme disease, hepatitis viruses, mononucleosis, Anaplasmosis, EBV, Enterovirus, HIV, Influenza A and B, UA, and blood cultures were negative. ANA was negative. Acetaminophen level was WNL. Urine drug screen was negative.

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11 Differential Diagnosis HSV VZV Adenovirus CMV

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13 Noor et al (2018), Hepatitis caused by herpes viruses: A review. Journal of Digestive Diseases. HSV Hepatitis HSV, is an enveloped, dsdna virus. Approximately 80% of adults are infected with HSV-1 in the Western world and approximately 30% are infected with HSV-2. Herpes labialis (mainly HSV-1) and genital herpes (mainly HSV-2) recur due to persistence of the virus in the neurons. Infection, reinfection, and recurrence are thought to occur mainly as a result of changes in cell-mediated immunity. HSV hepatitis is usually seen in the context of herpes sepsis and is almost exclusively restricted to immunocompromised individuals (HIV, transplant, pregnancy 2/2 hemodilution etc).

14 Noor et al (2018), Hepatitis caused by herpes viruses: A review. Journal of Digestive Diseases.

15 Noor et al (2018), Hepatitis caused by herpes viruses: A review. Journal of Digestive Diseases. HSV Hepatitis Signs and symptoms may be non-specific initially, but often include fever, RUQ abdominal pain, nausea, and vomiting. Jaundice may or may not be present. The classic herpes rash is present <50% of the time and absence of rash does not exclude herpes from the differential. Patients may be encephalopathic and laboratory tests may show transaminase levels that are 1000-fold the upper limit of normal. Coagulopathy and acute renal failure may also be present. Patients often deteriorate rapidly within a week of illness with clinically noticeable septic shock, liver necrosis, DIC, hypotension, and death.

16 HSV Hepatitis Major risk factors influencing mortality and need for liver transplantation include male sex, age >40 years, immunocompromised status, degree of AST elevation, coagulopathy and encephalopathy. Majority of cases progress to acute liver failure with a mortality rate of around 90%. HSV is responsible for 1% of all acute liver failure cases and 2% of all viral liver failures. Mortality can be as high as 51% despite treatment on acyclovir. Noor et al (2018), Hepatitis caused by herpes viruses: A review. Journal of Digestive Diseases.

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20 Main Takeaways HSV hepatitis is a rare cause of acute liver failure, particularly in immunocompetent individuals. Consider the diagnosis in the setting of non-zonal necrosis typically with scant inflammatory cells. Viral inclusions may look very similar to VZV and similar changes may be seen in adenovirus or CMV, so confirm with IHC and molecular testing Clinical clues including rash can be helpful and if there is any suspicion at all, acyclovir should be started immediately.

21 Dr. Andrea Barbieri Dr. Natalie Patel Dr. Jon Morrow Dr. Declan McGuone Dr. Brian West Dr. Jeff Wang Dr. Bruce Rottmann ACKNOWLEDGEMENTS

22 Sources/Citations/References: Noor, A., Panwala, A., Forouhar, F. and Wu, G. Y. (2018), Hepatitis caused by herpes viruses: A review. Journal of Digestive Diseases.. doi: / Norvell JP, Blei AT, Jovanovic BD, Levitsky J. Herpes simplex virus hepatitis: an analysis of the published literature and institutional cases. Liver Transpl 2007; 13: Arora, K. Herpes simplex virus hepatitis. PathologyOutlines.com website. Accessed September 20th, Bernal, William, et al. "Acute liver failure." The Lancet (2010): Roque-Afonso, Anne-Marie, et al. "Chickenpox-associated fulminant hepatitis that led to liver transplantation in a 63-year-old woman." Liver Transplantation 14.9 (2008): Mannan, A.A.S.R. Cytomegalovirus hepatitis (CMV). PathologyOutlines.com website. Accessed November 13th, Mannan, A.A.S.R. Adenovirus hepatitis. PathologyOutlines.com website. Accessed November 13th, 2018.