Fulminant Hepatitis A and E Co-infection Leading to Acute Liver Failure: A Case Report

Abstract

Acute liver failure (ALF) is a severe clinical condition with a high mortality rate. Although several factors can cause ALF, viral hepatitis remains one of the leading causes. Hepatitis A virus (HAV) and hepatitis E virus (HEV), which typically cause self-limiting acute disease, are rare but emerging causes of ALF, especially when both viruses infect the same individual. Both of these hepatotropic viruses share an enteric route and are most commonly transmitted through the fecal-oral route. The impact of HAV/HEV coinfection on acute hepatitis prognosis is not entirely understood, but dual infection can further exacerbate liver damage, leading to fulminant hepatic failure (FHF) with a higher mortality rate than a single virus infection.Here, we present a case of a 32-year-old male with no prior liver disease who presented to the emergency department with a two-week history of jaundice, abdominal pain, and hepatomegaly. Upon admission, he was disoriented with grade 2 encephalopathy. After a thorough investigation, co-infection with hepatitis A and E was identified as the primary cause of his ALF. The patient underwent intensive medical treatment and interventions, including dialysis. Unfortunately, the patient's survival was not possible due to the absence of availability of a transplanted organ, which is currently the only definitive treatment option. This case report underscores the significance of prompt diagnosis, timely intervention, and the accessibility of transplantation in the survival of liver failure, as it remains the sole definitive treatment for acute liver failure. Moreover, it provides a concise overview of the current literature on fulminant co-infection of HAV and HEV, including epidemiology, clinical characteristics, pathogenesis, diagnosis, treatment, and risk factors associated with co-infection of hepatitis A and E and their role in causing ALF. It also highlights the significance of identifying high-risk populations and implementing appropriate prevention and control measures such as vaccination, practising good hygiene and sanitation, and avoiding the consumption of contaminated food and water.

High Incidence of Acute Liver Failure among Patients in Egypt Coinfected with Hepatitis A and Hepatitis E Viruses

“…The five co-infected patients in this study developed coagulopathy, jaundice, and encephalopathy. Similarly, several reports and case studies showed that HAV-HEV coinfection could be complicated by encephalopathy, jaundice, cholecystitis, and fulminant hepatic failure, which could eventually to death [17,64,68].…”

Recovery fulminant hepatitis A in systemic juvenile idiopathic arthritis patient treated with tocilizumab: a case report

“…Although acute infections with the hepatitis A virus in children are self-limited, 0.1% of patients progress to fulminant hepatic failure that spontaneously Z recovers in 40% of cases 6 , 16 . Defining the root cause of ALF is ambiguous.…”

“…Defining the root cause of ALF is ambiguous. Hepatitis A and E account for an enormous percentage of cases worldwide of acute liver failure, with a mortality rate exceeding 50%, especially in developing countries 16 .…”

“…This is seen in patients with chronic liver disease or people during pregnancy. There is even a risk of coma and liver and kidney failure 6 , 16 . Our patient had mental confusion.…”

Hepatitis A Virus and Hepatitis E Virus as Food- and Waterborne Pathogens—Transmission Routes and Methods for Detection in Food

“…Wang and colleagues identified two mutations in the ORF1 of HEV-1 that enhanced viral replication and may be associated with FHF [ 32 ]. Rarely, HEV can lead to ALF not only in pregnant women but also in elderly patients, patients with leukaemia or coinfection with other hepatotropic viruses [ 33 , 34 , 35 ]. HEV-3 and HEV-4, on the other hand, do not appear to cause fatal infections with fulminant hepatitis in pregnant women, but this has to be confirmed in future studies [ 36 ].…”