Acute liver failure, autoimmune hepatitis, and leptospirosis: a case report

Pediatric acute liver failure: Current perspective in etiology and management

Pediatric acute liver failure (PALF) is a catastrophic clinical condition with very high morbidity and mortality without early detection and intervention. It is characterized by the acute onset of massive hepatocellular injury that releases circulating inflammatory mediators, resulting in metabolic disturbances, coagulopathy, hepatic encephalopathy and multi-organ failure. The etiological spectrum is dominated by hepatotropic viruses, drug-induced liver injury, metabolic and genetic disorders and immune-mediated diseases. Unlike adults, indeterminate causes for acute liver failure constitute a considerable proportion of cases of acute liver failure in children in the west. The heterogeneity of age and etiology in PALF has led to difficulties in developing prognostic scoring. The recent guidelines emphasize prompt identification of PALF, age-appropriate evaluation for hepatic encephalopathy and laboratory evaluation with careful monitoring. Current therapy focuses on supporting the failing liver and other organs, pending either spontaneous recovery or liver transplantation. Targeted therapy is available for a select group of etiologies. Liver transplantation can be lifesaving and a plan for the same should be organized, whenever indicated. The aim of this review is to define PALF, understand its etiopathogenesis, address the challenges encountered during the management and update the latest advances in liver transplantation and non-transplant treatment options in PALF.

Crossroad of infection and autoimmunity in acute liver failure: a case report

Background

Acute liver failure (ALF) is a syndromic diagnosis, consisting of jaundice, coagulopathy, and any degree of encephalopathy in a patient without pre-existing liver disease within 26 weeks of the onset of symptoms. Autoimmune hepatitis has a wide range of presentations and can rarely present as ALF, which frequently tends to be autoantibody negative. Tropical infections like dengue, malaria, and leptospirosis, which present as mimickers of ALF, always remain a differential diagnosis of ALF and mandate an etiology specific management. In rare cases, such infections themselves act as a trigger for autoimmunity. We report a case of diagnostic crossroads of infection and autoimmunity, presenting as acute liver failure and describe the challenges in management.

Case presentation

A 25-year-old female presented with a syndromic diagnosis of acute liver failure with possibility of tropical illness-related ALF mimic on account of positive Leptospira serology. After initial improvement, there was a rebound worsening of liver functions which prompted a liver biopsy. Biopsy narrowed the differential to Leptospira-associated hepatitis and severe auto-immune hepatitis. Trial of low dose steroid was given which led to dramatic improvement.

Conclusion

Tropical infections can present as ALF mimics and can themselves act as triggers for autoimmunity. Distinguishing such cases from de-novo acute severe autoimmune hepatitis is difficult and requires therapeutic brinksmanship. An early trial of steroid is mandated but comes with its own challenges.

Weil's disease (leptospirosis) manifesting as fulminant hepatic failure: report of an autopsy case

We report an autopsy case of a 60-year-old man with Weil's disease who died of fulminant hepatic failure. Ante-mortem blood culture yielded the growth of Leptospira interrogans (serovar icterohaemorrhagiae). At autopsy, the liver weighed 1210 g and showed a typical appearance of "acute yellow liver atrophy". Zone 3 (centrilobular region) showed submassive necrosis of hepatocytes accompanied by marked hemorrhage. Hepatocytes in zones 1 and 2 were well preserved, and the leptospira antigen was immunohistochemically demonstrated in several hepatocytes. Dissociation of liver cell plates was not observed. An immunohistochemical study demonstrated that CD31-positive, sinusoidal endothelial cells had almost completely disappeared in zone 3. This finding suggested that severe and selective damage to endothelial cells in zone 3 was the main cause of the submassive hepatocellular necrosis, which led to fulminant hepatic failure in the present case.

Bakterielle Infektionen: Atypische Bakterien

Chlamydophila (früher Chlamydia) pneumoniae ist im Kindesalter ein seltener Erreger respiratorischer Infektionen, vor allem der Pneumonie, wenn die PCR als direkte Nachweismethode herangezogen wird. Die höhere Nachweisrate von Antikörpern gegen C. pneumoniae deutet auf eine hohe Rate asymptomatischer oder unspezifischer Infektionen durch C. pneumoniae hin.

Der Mensch ist weltweit das einzige Erregerreservoir. Kranke, seltener auch asymptomatische Ausscheider (Wochen bis 1 Jahr) sind die Ansteckungsquelle. Die Übertragung erfolgt als „Tröpfcheninfektion“ mit respiratorischen Sekreten. Eine epidemische Krankheitshäufung ist beschrieben. In feuchtem Milieu können Chlamydien bis zu 30 h auf unbelebtem Material überleben.

Im Erwachsenenalter haben 50–75 % der Bevölkerung Antikörper gegen C. pneumoniae. Die höchsten Titer werden in der Altersklasse der 5- bis 14-Jährigen gefunden – ein Indiz für das Hauptmanifestationsalter der Primärinfektion. Seroprävalenzdaten aus Deutschland decken sich mit den Angaben aus der internationalen Literatur (5 % der unter 10-Jährigen, 64 % der unter 18-Jährigen besitzen Antikörper gegen C. pneumoniae). Ambulant erworbene Pneumonien werden im Kindesalter möglicherweise in bis zu 18 % der Fälle (serologische Diagnose) durch C. pneumoniae verursacht. Untersuchungen mittels PCR hingegen weisen C. pneumoniae nur in sporadischen Fällen nach. Koinfektionen mit Mykoplasmen, aber auch Pneumokokken und Adenoviren sind keine Seltenheit.