S2471 A Fatal Case of Fulminant Hepatic Failure Associated With Hepatitis A Virus

Abstract

INTRODUCTION: Hepatitis A Virus (HAV) is a RNA virus that is contagious and spread by fecal-oral transmission. It is a global public health concern with 1.4 million cases each year(1) and is typically a self-limited illness. Fulminant hepatic failure, acute liver failure with encephalopathy and impaired synthetic function, occurs in less than one percent of cases(1). We present a case of unresolving HAV infection leading to fulminant liver failure and death. CASE DESCRIPTION/METHODS: An 83-year-old female with CAD presented with 3 days of lethargy. Vital were normal and exam revealed jaundice. Medications did not reveal hepatotoxic agents. Lab revealed glucose 21, lactate 6, bilirubin 4.9, AST 9291, ALT 8757, INR 13. Hepatitis panel positive for HAV IgM and negative IgG. EBV, CMV, HBV and HCV serology negative. Autoimmune work up, urine toxicology and acetaminophen levels were negative. Doppler showed mild intrahepatic ductal dilation with no thrombosis. Despite improving transaminases, she became encephalopathic for which lactulose enemas were given. She was transferred to the ICU for grade-3 hepatic encephalopathy. It was discovered the patient received food donations from multiple sources. Liver transplant centers were consulted however the patient was denied candidacy given age and comorbidities. Improvement in liver enzymes were indicative of liver exhaustion as the patient’s condition deteriorated. She eventually required vasopressor support. After discussions with palliative care, patient was transitioned to comfort care and passed. DISCUSSION: The incidence of HAV declined from 6 to 0.4 per 100,000 between 1999 and 2014(5). Introduction of HAV vaccine, measures to improve food preparation, sanitation and educational initiatives are likely explanations for decreasing incidence. Despite this, our case demonstrates a fatality as a result of fulminant HAV in an elderly female, in a developed nation, with no recent history of travel or evidence of prior immunity or coinfection. Fulminant liver failure occurs more commonly in individuals >50 years with other liver diseases such as hepatitis B and C(2). The source of infection in our patient is unclear although suspicion of foodborne illness remains and whether prior immunity would have improved her outcome. Interestingly, only 1/3 of the United States have serological immunity and additional measures are needed to avoid sporadic cases of acute HAV which have the potential to cause fulminant hepatic failure and death(4).