Acute Liver Failure due to Disseminated Varicella Zoster Infection

Abstract

Acute liver failure (ALF) can be due to numerous causes and result in fatality or necessitate liver transplantation if left untreated. Possible etiologies of ALF include ischemia, venous obstruction, medications, toxins, autoimmune hepatitis, metabolic and infectious causes including hepatitis A-E, varicella-zoster virus (VZV), cytomegalovirus (CMV), herpes simplex virus (HSV), Epstein-Barr virus (EBV), and adenovirus with VZV being the most rarely reported. Pathognomonic skin lesions facilitate diagnosis of VZV hepatitis, but definitive diagnosis is secured with liver biopsy, tissue histopathology, culture, and specific VZV polymerase chain reaction (PCR). Antiviral treatment with intravenous acyclovir can be effective if initiated in a timely manner; however, comorbidities and complications frequently result in high mortality, especially in immunocompromised hosts as exemplified in this case presentation.

Rare presentation of primary varicella zoster as fatal fulminant hepatitis in adult on low-dose,short-term steroid: Case report

“…The differential diagnosis of FAHF includes venous obstruction, ischemia, toxins, medications, autoimmune hepatitis, metabolic and infectious causes (primarily viruses, e.g. hepatitis A-E, VZV, CMV, EBV, HSV, and adenovirus), with VZV being the rarest [10]. Our patient's history and clinical findings did not suggest ischemic hepatitis, and he did not have history of exposure to toxins or alcohol ingestion.…”

“…Definitive diagnosis of VZV hepatitis can be made by liver biopsy, histopathology, culture, or VZV PCR [10]. Testing for VZV IgG might differentiate primary infection (negative IgG) from secondary reactivation (positive IgG) [4].…”

“…In terms of treatment, the diagnosis of visceral VZV infection is often difficult due to atypical presentation, so treatment is often delayed [10]. Prompt empirical therapy with acyclovir and VZV immunoglobulin while awaiting PCR results is warranted if clinically suspected [16].…”

“…Fulminant acute hepatic failure (FAHF) due to VZV hepatitis is extremely rare and deadly, with only 9 cases reported in the literature. Seven of these nine cases were immunocompromised patients, one was 15 year old child and only one case was on short term steroid treatment; most of them died of the disease [[2], [3], [4], [5], [6], [7], [8], [9], [10]]. In this paper, we present, to the best of our knowledge, the second case of VZV FAHF to develop in a healthy adult on low dose steroid that unusually presented initially as acute abdomen.…”

Intensive Care Management of Acute Liver Failure: Considerations While Awaiting Liver Transplantation

“…Cytomegalovirus, varicella-zoster, Epstein-Barr, and adenovirus have all been reported as viral causes of ALF, albeit rare, particularly in pediatric or immunocompromised populations. [22][23][24] Autoimmune hepatitis may present with ALF. 6 Initiation of steroid therapy may be considered for some patients (prednisone starting at 40-60 mg/day).…”