A rare case of acute liver failure with intrahepatic cholestasis due to dengue hemorrhagic fever: CytoSorb® and plasma exchange aided in the recovery: case report

Abstract

Background Dengue haemorrhagic fever is a severe form of acute dengue infection characterized by leakage of plasma through capillaries into body spaces resulting in circulatory insufficiency leading to shock. Despite varying degrees of liver involvement occurring in acute dengue infection, intrahepatic cholestasis is very rare in the literature with only two cases reported so far. We report a challenging case of a middle-aged woman with DHF complicated by acute liver failure, coagulopathy, acute renal failure and prolonged intrahepatic cholestasis. She was successfully managed in the intensive care unit with supportive therapy, Cytosorb® and therapeutic plasma exchange. Case presentation A 54-year-old Sri Lankan obese woman with multiple comorbidities presented with fever, headache, vomiting and generalized malaise for 3 days and was diagnosed with dengue haemorrhagic fever. Despite the standard dengue management, she clinically deteriorated due to development of complications such as, acute liver injury, intrahepatic cholestasis and acute renal injury. Acute liver failure was evidenced by transaminitis, lactic acidosis, coagulopathy with pervaginal bleeding and severe encephalopathy necessitating elective intubation and mechanical ventilation. She was immediately transferred to intensive care facilities where she underwent supportive management for liver failure, continuous renal replacement therapy coupled with cytosorb and therapeutic plasma exchange with which she made a remarkable recovery. Conclusion Acute liver failure with a prolonged phase of intrahepatic cholestasis is a very rare complication of acute dengue illness which is sparsely documented in medical literature so far. This patient was managed successfully with supportive therapy, aided by cytoSorb hemo-adsorption and therapeutic plasma exchange.

Dengue induced acute liver failure: A meta summary of case reports

“…Although no specific treatment is recommended, there is increasing interest in using intravenous N-acetylcysteine (NAC) for managing such cases. Even in our cohort, 6 (31.6%) patients were administered NAC for ALF, albeit in different doses and wide variation of duration[ 12 , 15 , 16 , 17 , 20 , 30 ]. NAC is the recommended antidote for managing ALF secondary to paracetamol overdose[ 40 ], but is increasingly been used in managing non-paracetamol related ALF[ 41 ].…”

“…Therapies like cytokine filtration, plasma exchange and molecular adsorbent recirculating system have also been used in patients with severe ALF. However, large scale data is missing to recommend their routine use[ 20 , 25 ].…”

Liver involvement in dengue: A systematic review

“…19,20,25,27,30,31,36,40,47,61,75,110,112,118,125,130,133,143,[149][150][151] Transaminase elevation was detected between symptom onset and day 8. 41,48,51,54,55,80,140,141,145,147,152,153 Longitudinal sampling of dengue patients showed that the rise in transaminases had often already started at the first sampling time point, usually between day 1 and 5 from disease onset. 16,24,41,48,54,57,59,152,154,155 Transaminase levels increased during hospitalisation, 47 and from week 1 to 2 postsymptom onset, 47 usually peaking between day 1 and 11 postsymptom onset 16,24,27,42,52,54-57,59,67,68,74,85,91,94,104,135,139,141,144,152, 154-156 and occasionally during the convalescent phase.…”

Severe dengue infection unmasking drug‐induced liver injury: Successful management with N‐acetylcysteine

“…5 Severe dengue, independently capable of precipitating acute liver failure through direct hepatotoxicity, likely presents a significant compounding risk in patients receiving ATT. 6 Case reports 7,8 suggest complex interactions between dengue and hepatotoxic medications, potentially involving reduced clearance, aberrant hapten formation, and synergistic immunotargeting. 9 While isolated dengueinduced liver injury often resolves spontaneously, concomitant drug-induced acute liver failure carries a grave prognosis.…”

“…Case reports 7,8 suggest complex interactions between dengue and hepatotoxic medications, potentially involving reduced clearance, aberrant hapten formation, and synergistic immunotargeting 9 . While isolated dengue‐induced liver injury often resolves spontaneously, concomitant drug‐induced acute liver failure carries a grave prognosis 10 .…”