Chickenpox-associated fulminant hepatitis that led to liver transplantation in a 63-year-old woman

Could Herpesviridae be the cause of severe acute hepatitis of unknown origin in children?

INTRODUCTION

Severe acute hepatitis (SAH) is defined by a severe inflammation of hepatocytes in the liver parenchyma which can lead to an acute liver failure, a clinical condition with high mortality rate that can be triggered by several factors but is usually associated to hepatotropic viruses' infection. In 2022, cases of children with severe acute hepatitis of unknown origin hospitalized in Glasgow, Scotland, were reported. Possible causes of this condition include, but are not limited to, undiagnosed viral (and non-viral) infections, autoimmune hepatitis, drug and/or chemical toxicity, mitochondrial chain respiratory and metabolic disorders.

AREAS COVERED

Herpesviruses can cause severe acute hepatitis, but little is known about the role and the mechanisms of herpesviruses as a causative agent of this type of hepatitis. We review the role of herpesviruses as causative agent of SAH in children and other possible mechanisms involved in this disease.

EXPERT OPINION

Differential diagnosis for herpesvirus in SAH should be implemented in all settings. Alternative fluids, such as saliva and dried blood, could be used in the diagnosis to overwhelm the availability of biological specimens at sufficient volume. In the future, genetic studies could also be added to increase the knowledge about severe acute hepatitis in children.

Outbreak control of hospital acquired varicella infection amongst health care workers in a tertiary care hospital

Background

Adult and immunocompromised patients suffering from varicella (chicken pox) are potential source of infection to healthcare workers. An outbreak of varicella among healthcare workers in a tertiary care centre was investigated, and preventive measures were implemented.

Methods

Cases of chicken pox between 05 Feb 2017 and 11 Feb 2017 in a tertiary healthcare establishment were investigated. An epidemiological investigation by developing case definitions, spot map and contact tracing was conducted. Eight cases were identified among healthcare workers. Suitable preventive measures including identification of susceptible contacts and vaccination of susceptible ones with two doses of varicella vaccine was undertaken.

Results

Index case was a 21-year-old nurse who was exposed to a 34-year-old male patient transferred from a secondary care hospital on 24 Jan 2017 as a case of acute liver failure and coagulopathy. Primary case was later diagnosed as case of varicella based on serological and clinical evidence. Among a total of 8 cases identified in the outbreak, the cases occurred among healthcare workers of secondary care centre, healthcare workers managing the primary case in the intensive care unit and who conducted the autopsy. A total of 181 contacts were identified in the epidemiological investigation, and 54 were susceptible to chicken pox. Two-dose immunization with varicella vaccination of susceptible ones was found to be effective in preventing further cases.

Conclusion

Two-dose vaccination of healthcare workers with varicella vaccine is an effective strategy to prevent nosocomial varicella among healthcare workers.

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

Background

Varicella zoster virus presents clinically as primary (chickenpox) or secondary (herpes zoster) infection. Cutaneous and extracutaneous dissemination may occur, usually in immunocompromised patients. VZV hepatitis that progresses to fulminant hepatic failure is very rare and fatal. To the best of our knowledge, 9 cases have been reported to date, of which 7 were in immunocompromised adults, and only one patient was on short duration steroid therapy.

Presentation of case

We present a 26-year old man who was admitted initially with acute abdomen as query persistent biliary colic. Later, he showed clinical and laboratory findings of VZV hepatitis that progressed rapidly despite maximal medical ICU support and he expired on day 3 of admission.

Conclusions

Acute VZV infection may present as fulminant hepatitis. The presentation may initially be challenging for the diagnosis and should be considered if the patient has been in contact with a sick case. Low dose corticosteroid could carry a risk for fatal VZV fulminant hepatitis and should be used very cautiously especially with VZV patients' contacts. Further causative relationships remain to be established.

Simultaneous Occurrence of Varicella Zoster Virus-Induced Pancreatitis and Hepatitis in a Renal Transplant Recipient: A Case Report and Review of Literature

INTRODUCTION

Gastrointestinal complications are common after renal transplantation, including oral lesions, esophagitis, gastritis, diarrhea, and colon carcinoma. The differential diagnosis is difficult in this scenario because multiple factors such as drugs, infections, and preexisting gastrointestinal disease come into play.

CASE PRESENTATION

We report a case of varicella zoster virus-induced pancreatitis and hepatitis in a renal transplant recipient. The patient underwent renal transplantation 3 years earlier and now presented with severe pain in the epigastrium radiating to his back and had raised serum lipase levels and skin lesions characteristic of varicella. Liver enzyme levels were also elevated. He was started on a regimen of acyclovir. His pain improved in 24 hours, and liver enzyme levels returned to normal in 48 hours.

DISCUSSION

There is a paucity of literature on the simultaneous occurrence of varicella zoster virus-induced hepatitis and pancreatitis in both immunocompetent and immunocompromised patients. Our case highlights the gastrointestinal complications of varicella infection in immunocompromised patients that may precede the characteristic dermatologic manifestations, and the fact that rarely both hepatitis and pancreatitis may be seen.

Viral Hepatitis: Other Viral Hepatides

Non-hepatotropic viruses cause acute hepatitis and/or acute liver failure, without causing any chronic damage to the liver. These viruses do not primarily target the liver. These viruses include the herpes viruses (Epstein-Barr virus, cytomegalovirus, and herpes simplex virus), parvovirus, adenovirus, influenza, and severe acute respiratory syndrome (SARS)-associated coronavirus.

The risk of acquiring infection from any of the non-hepatotropic viruses is specific to each virus. Infection with the herpesviruses is ubiquitous, with clinically significant hepatitis being less common. Considerations for determining the risk of hepatitis from non-hepatotropic viruses include prior exposure (risk of reactivation), host immune status (increase severity in immunosuppressed), and duration of infection in the contact.

Diagnosis is made with a combination of serology, polymerase chain reaction, or liver biopsy. Treatment is supportive in the majority. In certain clinical scenarios, such as cytomegalovirus infection in transplant patients, and acute liver failure from herpes simplex virus, specific antiviral therapy is warranted.

Varicella with rapidly progressive hepatitis presenting with multiple hepatic nodules in a child with acute leukemia

Abdominal pain may precede the characteristic varicella skin lesions in immunocompromised patients with visceral varicella. The absence of skin lesions may delay timely diagnosis and treatment of varicella for those patients. Furthermore, abdominal imaging findings to provide information to diagnose visceral varicella have rarely been reported. Varicella was diagnosed in a 5-year-old boy with acute lymphoblastic leukemia complaining of fever and abdominal pain followed by papulovesicular skin lesions. Later, the patient was found to have rapidly progressive acute hepatitis, and abdominal computed tomography showed multiple hypodense hepatic nodules. The patient was treated with intravenous acyclovir, intravenous immunoglobulin, and empirical antibiotic and antifungal therapy. However, his fever and abdominal pain persisted, and a laparoscopic liver biopsy was performed to differentiate other causes of the persisting symptoms. Eventually, the patient was diagnosed with visceral varicella based on histopathologic findings. In conclusion, visceral varicella should be considered in immunocompromised patients with abdominal pain and multiple hypodense hepatic nodules on abdominal imaging studies. However, bacteria, fungi, and tuberculosis can produce similar imaging findings; therefore, a biopsy may be necessary in patients not responding to antiviral therapy.

Successful rescue of disseminated varicella infection with multiple organ failure in a pediatric living donor liver transplant recipient: a case report and literature review

A 12-year-old female patient with biliary atresia underwent living donor liver transplantation (LDLT). Twelve months after the LDLT, she developed acute hepatitis (alanine aminotransferase 584 IU/L) and was diagnosed with disseminated varicella-zoster virus (VZV) infection with high level of serum VZV-DNA (1.5 × 10⁵ copies/mL) and generalized vesicular rash. She had received the VZV vaccination when she was 5-years-old and had not been exposed to chicken pox before the LDLT, and her serum was positive for VZV immunoglobulin G at the time of the LDLT. Although she underwent treatment with intravenous acyclovir, intravenous immunoglobulin, and withdrawal of immunosuppressants, her symptoms worsened and were accompanied by disseminated intravascular coagulation, pneumonia, and encephalitis. These complications required treatment in the intensive care unit for 16 days. Five weeks later, her clinical findings improved, although her VZV-DNA levels remained high (8.5 × 10³copies/mL). Oral acyclovir was added for 2 weeks, and she was eventually discharged from our hospital on day 86 after admission; she has not experienced a recurrence. In conclusion, although disseminated VZV infection with multiple organ failure after pediatric LDLT is a life-threatening disease, it can be cured via an early diagnosis and intensive treatment.

Acute liver failure due to Varicella zoster virus infection after lung transplantation: a case report

Most adults are Varicella zoster virus (VZV)-positive at the age of 20 years. Some, however, remain antibody-negative and may develop primary chicken pox during adulthood. We report a patient with Williams-Campbell syndrome who underwent double-lung transplantation while being VZV-negative. One year after the successful procedure, he was admitted with fulminant hepatic failure and some cutaneous vesicles in his face. Despite a rapid diagnosis of VZV infection and treatment with acyclovir, his situation deteriorated within 24 hours and while awaiting an urgent liver transplantation, he developed multiple organ failure and died.

Epidemiology of liver failure

The etiology of fulminant hepatitis varies in different countries and at different times. The main causes of fulminant hepatitis are viruses, paracetamol, drugs (other than paracetamol), poisons and 15-30% remained of undetermined origin. The prevalence of these etiologies varies according to the geographic region and has changed over the past 10 years. Paracetamol has now overtaken viruses (particularly hepatitis B virus) as the leading cause of fulminant hepatitis. Establishing the cause of fulminant hepatitis is an important step in the management of acute liver failure, so that specific therapy can be initiated and any contraindications to liver transplantation be eliminated.

Etiology and prognosis of fulminant hepatitis in adults

1. Establishing the cause of fulminant hepatitis is an important step in the management of acute liver failure, so that specific therapy can be initiated and any contraindications to liver transplantation can be eliminated. 2. The etiology of fulminant hepatitis varies in different countries and at different times. A viral etiology (in particular hepatitis B virus) is now less frequent, and paracetamol-induced fulminant hepatic failure is more common. 3. Many patients have miscellaneous causes of fulminant hepatitis. It is important to establish the main clinical and biological characteristics for specific management. 4. Assessment of the prognosis of fulminant hepatitis is important for distinguishing patients requiring liver transplantation from those whose will improve spontaneously. Prognosis depends on several factors, including the gold standard, the King's College Hospital criteria and Clichy's criteria.