Use of intravenous N-acetylcysteine in acute severe hepatitis due to severe dengue infection: a case series

Abstract

Background Dengue fever is a common mosquito borne viral infection. Severe dengue fever associated severe hepatitis carries high mortality. Based on the beneficial effect of N-acetylcysteine (NAC) in paracetamol poisoning and non-acetaminophen induced liver failure, it is used in dengue fever associated hepatitis in clinical practice. We aim to study the reversal of liver enzymes with NAC in the setting of severe hepatitis due to severe dengue infection. Methods A retrospective analysis was conducted on hospitalized 30 adults with severe dengue fever with severe hepatitis. These 30 patients had aspartate transaminase (AST) and alanine transaminases (ALT) more than 500 U/L and/or PT INR (prothrombin time and international normalized ratio) more than 1.5. They were treated with NAC infusion of 100 mg/h for 3 to 5 days. Results The mean age of the group was 49.9 ± 11.46 years and 18 (60%) patients were males. Nineteen patients (63%) developed dengue shock. Of them 12 patients (40%) developed hepatic encephalopathy. Median AST on the day of administration of NAC was 1125 U/L interquartile range (IQR) 1653.25 while median ALT was 752 (IQR 459.25). There was a statistically significant reduction of both ALT (p = 0.034) and AST (p = 0.049) from day 1 to 4 after NAC infusion. Rise of platelet count between day 1 and day 4 also showed statistically significant difference (p = 0.011) but the reduction of prothrombin time and international normalized ratio (PT/INR) from 1 to day 4 did not show statistical significance difference. Mean duration of treatment with NAC was 3.61 ± 0.75 days while mean length of hospital stay was 6.2 ± 1.27 days. Only one patient died (3.3%). None of the patients reported adverse drug reaction due to NAC. Conclusion Majority of patients demonstrated marked clinical and biochemical improvements and they recovered fully. We observed faster and significant recovery of liver enzymes following administration of NAC. Based on the above findings, this study provides preliminary evidence for the beneficial effect of NAC in severe hepatitis in dengue infection with greater survival benefits.

Successful results of early nucleos(t)ide analogue treatment for liver transplantation candidates with severe acute hepatitis B infection

“…Deterioration of severe acute HBV infection to ALF was prevented in 22 of the 24 cases (92%). These patients could be discharged after median (range) 12 (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) days following initiation of the antiviral drug. Median (range) maximum ALT, total bilirubin and INR levels were as follows: 2534 (1176-5679) U/L, 17 (10-38) mg/dL and 1.7 (1.4-3.2); median(interquartile range) viral load was 63 000 (23 600-3 680 000) copies/mL.…”

“…Over time, this evolved to a standard protocol for all patients: 100 mg/kg/day NAC for 72 h, lactulose at a dose titrated to achieve 2-3 defecations per day and 15 mg/kg/ day ursodeoxycholic acid to all patients without vomiting. Although the initially suggested role of NAC in early stage non-acetaminophen ALF [12] has not been confirmed in randomized trials [13], the absence of an obvious negative effect [13] and encouraging reports on its effects in acute-on-chronic hepatitis B [14], as well as hepatitis due to other hepatotropic viruses [15][16][17], led to its inclusion in the standard protocol.…”

Acute Liver Failure in Dengue: A Common but Overlooked Entity in Pediatric Patients in Tropical Countries

“…Management of ALF in dengue infection is largely supportive in an intensive care setting. Some of the centers have used NAC in adults with variable results but it is not part of our management protocol and its use was sporadic (21,22). We did not find any significant difference in survival with the use of NAC though Sriphongphankul et al (16) from Thailand found it to be beneficial in dengue PALF.…”

Utilização do paracetamol no tratamento da dengue e o comprometimento do fígado: revisão

“…Tal dano ocorre em pacientes com dengue e isso se deve à toxicidade viral ou por uma resposta imune desregulada ao vírus. Normalmente, promove alterações nos marcadores bioquímicos, principalmente, o aspartato aminotransferase (AST) e a alanina aminotransferase (ALT), alterações observadas, inclusive, em pacientes assintomáticos (Cesar;Piloto, 2015;Wan et al, 2018;Seneviratne, 2018;Tafere;Wondafrash;Demoz, 2020;Dissanayake et al, 2021).…”