Two Liver Transplant Center’s Experience of Dengue-Associated Acute Liver Injury

Abstract

Background: Acute liver failure is an uncommon, but often fatal, complication of dengue virus infection in adults. Aims: In this study, we aimed to evaluate the occurrence of a major adverse event to propose a management strategy. Methods: The files of seven patients hospitalised for dengue virus infection and severe acute liver injury from 1997 to 2013 were reviewed. Results: High levels of serum aminotransferases, bilirubin, and severe coagulopathy were observed. All patients had ingested acetaminophen during the last 3-5 days. Among them four had grade 0-I encephalopathy when N-acetylcysteine was administered intravenously. Two of them showed mediolobular liver necrosis, as observed in dengue virus-infected patients. One of these two patients developed severe metabolic acidosis and grade 4 encephalopathy despite continuous administration of N-acetylcysteine for 2 days but survived because of orthotopic liver transplantation. The two others had documented features of acetaminophen hepatotoxicity, with acute liver failure in one of them, but both survived. The remaining 3 patients developed acute liver failure with grade IV encephalopathy, hypotension, and renal failure. They died after protracted shock and medioor panlobular liver necrosis despite administration of delayed N-acetylcysteine. Conclusions: In cases of dengue-associated severe acute liver injury, acetaminophen administration is contraindicated, and N-acetylcysteine should be immediately administered with or without encephalopathy. Liver transplantation is the only therapeutic alternative for persistent acute liver failure, despite N-acetylcysteine.