Abstract
Acute liver failure (ALF) is a severe condition in which liver function rapidly deteriorates in individuals without prior history of liver disease. While most cases result from acetaminophen overdose or viral hepatitis, in up to a third of patients, no clear cause can be identified. Liver transplantation has greatly reduced mortality among these patients, but 40% of patients recover without liver transplantation. Therefore, there is an urgent need for rapid determination of the etiology of acute liver failure. In this case report, we present a case of herpes simplex 2 virus- (HSV-) associated ALF in an immunocompetent patient. The patient recovered without LT, but the presence of HSV was not suspected at the time, precluding more effective treatment with acyclovir. To determine the etiology, stored blood samples were analyzed using whole transcriptome shotgun sequencing followed by mapping to a panel of viral reference sequences. The presence of HSV-DNA in blood samples at the time of admission was confirmed using real-time polymerase chain reaction, and, at the time of discharge, HSV-DNA levels had decreased by a factor of 106. Conclusions. In ALF cases of undetermined etiology, uncommon causes should be considered, especially those for which an effective treatment is available.
Highlights
Acute liver failure (ALF), called fulminant hepatic failure, is a rare but life-threatening condition characterized by sudden deterioration of liver function and associated with coagulopathy and hepatic encephalopathy [1, 2]
ALF implies that the patient had no prior history of liver disease or cirrhosis [2], providing few clues to the underlying etiology, and the rapid onset and difficulty of identification at the earliest stages may lead to delays in the start of treatment
Herpes simplex virus (HSV) infection is an uncommon cause of ALF that typically occurs following reactivation as a result of pregnancy or immunosuppression [13,14,15]
Summary
Acute liver failure (ALF), called fulminant hepatic failure, is a rare but life-threatening condition characterized by sudden deterioration of liver function and associated with coagulopathy (international normalized ratio ≥ 1.5) and hepatic encephalopathy [1, 2]. Aside from hepatitis viruses A, B, and E, other viruses including parvovirus B19, SEN virus, echovirus 18, and several members of the Herpesviridae (e.g., herpes simplex, herpes zoster, Epstein-Barr, and cytomegalovirus) have been reported to cause ALF in rare cases [6,7,8,9]. Herpes simplex virus (HSV) infection is an uncommon cause of ALF that typically occurs following reactivation as a result of pregnancy or immunosuppression [13,14,15]. It is rarely identified until after death or liver transplantation (LT) [13]. We suggest the usefulness of generation RNA sequencing and real-time polymerase chain reaction of stored blood samples for retrospective identification of pathogens causing ALF from stored blood samples
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