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Mitra S, Hanumanthappa MK, Sarkar S, Bhalla A, Minz R, Ratho RK. Epstein Barr Virus-Related Acute Liver Failure and Hemophagocytosis in an Immunocompetent Individual: An Autopsy Report. Int J Surg Pathol 2024; 32:838-844. [PMID: 37723947 DOI: 10.1177/10668969231195068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Epstein-Barr virus (EBV) is a nonhepatotropic virus. It causes mild self-limiting illness characterized by fever, oral ulcer, diarrhea, lymphadenopathy, and hepatosplenomegaly. Rarely it causes acute liver failure (ALF). EBV-related ALF (EBV-ALF) accounts for 0.2% of all ALF cases. The prognosis of EBV-ALF is dismal, and it can affect both immunocompromised and immunocompetent individuals. We performed a partial autopsy on a 30-year-old immunocompetent individual with infectious mononucleosis and ALF. The autopsy showed characteristic histomorphology of EBV-ALF in the form of centrizonal confluent hepatocytic necrosis, portal mixed inflammatory infiltrate, sinusoidal lymphocytosis, numerous hemophagocytic figures, and tissue Epstein-Barr encoded RNA-in situ hybridization (EBER-ISH) positivity. Extensive hemophagocytosis was noted in the liver, spleen, lymph node, and bone marrow. Other features include T-zone expansion of lymph nodes and spleen, interstitial pneumonia pattern in the lungs, and exanthematous skin changes. EBV-DNA polymerase chain reaction from the postmortem blood sample yielded 70,200 copies/µL. The index case highlights the uncommon occurrence of EBV-ALF, its histomorphological features, and its putative pathogenesis.
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Affiliation(s)
| | | | | | - Ashish Bhalla
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Ranjana Minz
- Department of Immunopathology, PGIMER, Chandigarh, India
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Hrynkiewicz R, Niedźwiedzka-Rystwej P. Etiology of viral induced acute liver failure and defensins as potential therapeutic agents in ALF treatment. Front Immunol 2023; 14:1153528. [PMID: 37153560 PMCID: PMC10160486 DOI: 10.3389/fimmu.2023.1153528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023] Open
Abstract
Acute liver failure (ALF) is a rare and severe disease, which, despite continuous advances in medicine, is still characterized by high mortality (65-85%). Very often, a liver transplant is the only effective treatment for ALF. Despite the implementation of prophylactic vaccinations in the world, the viral background of ALF is still a problem and leads to many deaths. Depending on the cause of ALF, it is sometimes possible to reverse this condition with appropriate therapies, which is why the search for effective antiviral agents seems to be a very desirable direction of research. Defensins, which are our natural antimicrobial peptides, have a very high potential to be used as therapeutic agents for infectious liver diseases. Previous studies on the expression of human defensins have shown that increased expression of human α and β-defensins in HCV and HBV infections is associated with a better response to treatment. Unfortunately, conducting clinical trials for ALF is very difficult due to the severity of the disease and the low incidence, therefore animal models are important for the development of new therapeutic strategies. One of the best animal models that has real reference to research on acute liver failure (ALF) is rabbit hemorrhagic disease in rabbits caused by the Lagovirus europaeus virus. So far, there have been no studies on the potential of defensins in rabbits infected with Lagovirus europaeus virus.
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Varga NI, Mateescu DM, Negrean RA, Horhat FG, Bagiu IC, Kodimala SC, Bandi SSS, Horhat RM, Horhat DI, Mot IC, Miutescu B. Diagnosis and Management of a Triple Infection with Leptospira spp., Hepatitis A Virus, and Epstein-Barr Virus: A Rare Occurrence with High Hepatotoxic Effect. Healthcare (Basel) 2023; 11:healthcare11040597. [PMID: 36833132 PMCID: PMC9956391 DOI: 10.3390/healthcare11040597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
The etiology of acute hepatic cytolysis is complex, and a thorough laboratory investigation is needed to find the causative agent and guide the clinician toward a specific treatment. Viral hepatitis A is a well-known cause of acute hepatitis, but other viruses and bacteria can lead to or contribute to liver damage. We report the case of a young male patient with triple infection with hepatitis A virus, Epstein-Barr virus, and Leptospira spp. To our knowledge, this is the first case of an HAV, EBV, and Leptospira triple infection, and it aims to bring awareness about the possibility of double or triple infection with such pathogens that are highly cytotoxic for the liver tissue since all three pathogens are known to cause or contribute to the onset of acute hepatitis. It was deduced that the source of the infection likely happened during a two-week visit to the countryside in Romania, returning 16 days before the onset of symptoms. The evolution was favorable receiving treatment with amoxicillin/clavulanic acid (1200 mg/8 h); glucose 5% 500 mL/day; 0.9% saline 500 mL/day; phenobarbital 1 tablet/day (200 mg); vitamins B1 and B6 and a complex of vitamin C and D3 and zinc. Lactulose syrup was also administered when the patient had no bowel movement for more than 24 h to prevent the onset of hepatic encephalopathy, and the patient was discharged after 20 days. This case suggests that a detailed anamnesis can raise suspicion about more uncommon causes of hepatic cytolysis and lead to a broader and more complex laboratory investigation, thus improving the quality of patient care. Yet, this is the only case previously reported to compare different management options and patient outcomes.
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Affiliation(s)
- Norberth-Istvan Varga
- Department of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Diana-Maria Mateescu
- Department of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | | | - Florin George Horhat
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence:
| | - Iulia-Cristina Bagiu
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Shiva Charana Kodimala
- MediCiti Institute of Medical Sciences, NTR University of Health Sciences, Hyderabad 501401, India
| | - Satya Sai Sri Bandi
- Malla Reddy Institute of Medical Sciences, Suraram Main Road 138, Hyderabad 500055, India
| | - Razvan Mihai Horhat
- Department of Conservative Dentistry and Endodontics, Faculty of Dental Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Delia Ioana Horhat
- Ear-Nose-Throat Department, “Victor Babes” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq, 300041 Timisoara, Romania
| | - Ion Cristian Mot
- Ear-Nose-Throat Department, “Victor Babes” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq, 300041 Timisoara, Romania
| | - Bogdan Miutescu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Abstract
Pediatric acute liver failure (PALF) is a life-threatening disorder characterized by acute hepatocellular injury occurring in children without recognized underlying liver disease. The clinicopathologic evaluation of PALF requires a different approach from that in adults. The diagnostic considerations differ depending on the age, personal and family history, geographical region, and clinical presentation. Distinct entities such as gestational alloimmune liver disease, herpes simplex virus infection, and metabolic disorders should be considered in neonates with acute liver failure, while acetaminophen toxicity and autoimmune hepatitis are more frequently seen in older children and adolescents. An identified cause for PALF despite a negative complete evaluation (indeterminate) is lacking in 30 to 50% of cases. Although not routinely performed in the setting of PALF, liver biopsy may be helpful in assessing the etiology, potential mechanisms of injury, determining the appropriateness of liver transplantation, and prognostication of the patients. In this article, we review the clinicopathologic characteristics of PALF with an emphasis on general approach of pathologic evaluation and histopathologic characteristic of selected entities.
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Affiliation(s)
- Juan Putra
- Division of Pathology, Department of Paediatric Laboratory Medicine, 7979The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology, and Nutrition, 7979The Hospital for Sick Children, Toronto, ON, Canada
| | - Antonio R Perez-Atayde
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Nakajima K, Hiejima E, Nihira H, Kato K, Honda Y, Izawa K, Kawabata N, Kato I, Ogawa E, Sonoda M, Okamoto T, Okajima H, Yasumi T, Takita J. Case Report: A Case of Epstein-Barr Virus-Associated Acute Liver Failure Requiring Hematopoietic Cell Transplantation After Emergent Liver Transplantation. Front Immunol 2022; 13:825806. [PMID: 35154146 PMCID: PMC8834065 DOI: 10.3389/fimmu.2022.825806] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/12/2022] [Indexed: 12/15/2022] Open
Abstract
Hepatic manifestations of Epstein-Barr virus (EBV) infection are relatively common, mild, and self-limiting. Although fulminant hepatic failure has been reported in a few cases, the contributing factors are unclear. This report discusses a pediatric case of EBV-associated acute liver failure that required urgent liver transplantation; however, liver damage continued to progress post-liver replacement. Monoclonal CD8+ T cells that preferentially infiltrated the native and transplanted liver were positive for EBV-encoded small RNA, suggesting a pathophysiology similar to that of EBV-associated hemophagocytic lymphohistiocytosis and chronic active EBV infection. Therefore, subsequent chemotherapy and hematopoietic cell transplantation was conducted, which led to cure. This is the first case of EBV-associated acute liver failure that relapsed post-liver transplant. As such, it sheds light on an under-recognized clinical entity: liver-restricted hyperinflammation caused by EBV-infected monoclonal CD8+ T cells. This phenomenon needs to be recognized and differentiated from hepatitis/hepatic failure caused by EBV-infected B cells, which has a relatively benign clinical course.
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Affiliation(s)
- Koji Nakajima
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Eitaro Hiejima
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Hiroshi Nihira
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Kentaro Kato
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Yoshitaka Honda
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Naoko Kawabata
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Itaru Kato
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Eri Ogawa
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Mari Sonoda
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Tatsuya Okamoto
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
| | - Junko Takita
- Department of Pediatrics, Kyoto University Hospital, Kyoto, Japan
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Activated CD8 T-cell Hepatitis in Children With Indeterminate Acute Liver Failure: Results From a Multicenter Cohort. J Pediatr Gastroenterol Nutr 2020; 71:713-719. [PMID: 32796431 DOI: 10.1097/mpg.0000000000002893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In many pediatric acute liver failure (PALF) cases, a diagnosis is not identified, and the etiology is indeterminate (IND-PALF). Our pilot study found dense CD8 T-cell infiltrates and increased T-cell clonality in liver specimens from IND-PALF patients. We aimed to validate these findings in a multicenter cohort with investigators blinded to diagnosis. METHODS PALF Study Group registry subjects with IND-PALF (n = 37) and known diagnoses (DX-PALF) (n = 18), ages 1 to 17 years, with archived liver tissue were included. Liver tissue slides were stained for T cells (CD8 and CD4), B cells (CD20), macrophages (CD163), perforin, and tissue resident-memory T cells (Trm, CD103), and scored as minimal, moderate, or dense. Lymphocytes were isolated from frozen liver tissue for T-cell receptor beta (TCRβ) sequencing. RESULTS Dense hepatic CD8 staining was found in significantly more IND-PALF (n = 29, 78%) compared with DX-PALF subjects (n = 5, 28%) (P = 0.001). IND-PALF subjects were more likely to have dense or moderate perforin (88% vs 50%, P = 0.03) and CD103 (82% vs 40%, P = 0.02) staining compared with DX-PALF subjects. TCRβ sequencing of 15 IND-PALF cases demonstrated increased clonal overlap compared with 6 DX-PALF cases (P = 0.002). CONCLUSIONS Dense infiltration of effector Trm CD8 T cells characterizes liver tissue from IND-PALF subjects. Increased clonality suggests the T-cell expansion is antigen(s)-driven as opposed to a nonspecific inflammatory response. These findings support CD8 staining as a new biomarker of the activated CD8 T-cell PALF phenotype. Future studies are needed to characterize potential antigens, host risk factors, and inflammatory pathways with the goal of developing targeted therapies.
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8
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Chapin CA, Burn T, Meijome T, Loomes KM, Melin-Aldana H, Kreiger PA, Whitington PF, Behrens EM, Alonso EM. Indeterminate pediatric acute liver failure is uniquely characterized by a CD103 + CD8 + T-cell infiltrate. Hepatology 2018; 68:1087-1100. [PMID: 29603342 DOI: 10.1002/hep.29901] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/28/2018] [Accepted: 03/23/2018] [Indexed: 12/16/2022]
Abstract
UNLABELLED The cause of pediatric acute liver failure (PALF) is unknown in up to 40% of cases. Evidence suggests that aberrant immune system activation may play a role. We hypothesized that indeterminate PALF cases would exhibit a unique pattern of hepatic inflammation. This was a retrospective and prospective study of PALF cases due to indeterminate (iPALF), autoimmune hepatitis, or known diagnosis (dPALF) etiology. Liver tissue sections were stained with immunohistochemical markers for cytotoxic T-cells (cluster of differentiation 8 [CD8]), perforin, and tissue resident memory T-cells (CD103) and scored as minimal, moderate, or dense. Lymphocytes were isolated from liver tissue for T-cell receptor beta sequencing and flow-cytometric studies. Thirty-three iPALF, 9 autoimmune hepatitis, and 14 dPALF cases were included. Dense hepatic infiltrates of CD8+ T-cells were found in 27 (82%) iPALF cases compared to 1 (7%) dPALF case (P < 0.0001). Perforin staining was dense or moderate in 19 (73%) of 26 iPALF cases compared to minimal in all 7 dPALF cases (P = 0.004); 16 (62%) of 26 iPALF cases had dense CD103 staining compared to none of the 6 dPALF cases (P = 0.001). T-cell receptor beta sequencing of iPALF cases demonstrated increased clonality compared to dPALF and control cases. Flow cytometry and immunohistochemistry revealed that iPALF intrahepatic leukocytes were predominantly tissue resident memory CD8+ T-cells. CONCLUSION Indeterminate PALF is characterized by a dense CD8+ T-cell hepatic infiltrate consistent with expansion of a tissue resident memory T-cell phenotype; CD8+ T-cells are a biomarker of immune dysregulation in iPALF and may be used to better identify and define this group. (Hepatology 2018).
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Affiliation(s)
- Catherine A Chapin
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Thomas Burn
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tomas Meijome
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathleen M Loomes
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hector Melin-Aldana
- Department of Pathology and Laboratory Medicine, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Portia A Kreiger
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Peter F Whitington
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Edward M Behrens
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Estella M Alonso
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Uchida H, Sakamoto S, Fukuda A, Sasaki K, Shigeta T, Nosaka S, Kubota M, Nakazawa A, Nakagawa S, Kasahara M. Sequential analysis of variable markers for predicting outcomes in pediatric patients with acute liver failure. Hepatol Res 2017; 47:1241-1251. [PMID: 28032939 DOI: 10.1111/hepr.12859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/01/2016] [Accepted: 12/26/2016] [Indexed: 02/08/2023]
Abstract
AIM Our aim was to analyze serial changes in the predictive variables and a scoring system retrospectively adapted to evaluate outcomes in pediatric patients with acute liver failure (ALF). METHODS We retrospectively collected data on 65 patients with ALF. The 65 patients were divided into two groups according to the need for liver transplantation (LT) as follows: LT group (n = 54) and non-LT group (n = 11). The early determination scoring system of the indications for LT proposed by the Intractable Hepato-Biliary Diseases Study Group of Japan (JIHBDSG) was used in our study. The area under the receiver operating characteristic curve (AUROC) was calculated for the JIHBDSG score between the LT group and non-LT group at the time of diagnosis (day 0) and day 3, and day 5 after the diagnosis. RESULTS A JIHBDSG score of >3 at day 5 was found to identify the patients requiring LT with 83.7% sensitivity, 81.8% specificity, and 83.3% diagnostic accuracy. Based on a comparison of AUROC values, the JIHBDSG score on day 5 (AUROC 0.91) was higher than that on day 0 (AUROC 0.75) and day 3 (AUROC 0.84). CONCLUSION We showed that a serial analysis of the JIHBDSG score might be useful for predicting outcomes of ALF in pediatric patients who fulfilled the criteria of LT indication in our center. However, further studies are needed to validate our results.
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Affiliation(s)
- Hajime Uchida
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takanobu Shigeta
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Nakazawa
- Division of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Division of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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10
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Zhang W, Chen B, Chen Y, Chamberland R, Fider-Whyte A, Craig J, Varma C, Befeler AS, Bisceglie AMD, Horton P, Lai JP. Epstein-Barr Virus-Associated Acute Liver Failure Present in a 67-Year-Old Immunocompetent Female. Gastroenterology Res 2016; 9:74-78. [PMID: 27785330 PMCID: PMC5040549 DOI: 10.14740/gr718e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2016] [Indexed: 02/07/2023] Open
Abstract
Acute liver failure (ALF) is a rare illness with a high mortality rate. The only favorable management is emergent liver transplantation. About 13% of ALF cases have no clear etiology. Epstein-Barr virus (EBV)-associated ALF accounts for less than 1% of all ALF cases, and is seen mostly in adults younger than 40 years. There are only a few cases of EBV-associated ALF in elderly immunocompromised adults. We report a case of ALF in an immunocompetent 67-year-old woman caused by EBV infection that was treated by orthotopic liver transplantation (OLT). The diagnosis of EBV-associated ALF was established by EBV-DNA polymerase chain reaction (PCR) and EBV-encoded RNA (EBER-RNA) in situ hybridization (EBER-RISH). The patient is currently doing well 6 months after transplantation without any evidence of clinical EBV infection. This case illustrates the importance of early recognition and diagnosis of EBV-associated ALF by detection of EBV from liver biopsy, especially when patients are immunocompetent and other causes are excluded. To the best of our knowledge, this is the first case of EBV-associated ALF present in an immunocompetent elderly female.
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Affiliation(s)
- Wei Zhang
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA; Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Betty Chen
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Yongxin Chen
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Robin Chamberland
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Alexa Fider-Whyte
- Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Julia Craig
- Department of Surgery, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Chintalapati Varma
- Department of Surgery, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Alex S Befeler
- Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Adrian M Di Bisceglie
- Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Peter Horton
- Department of Surgery, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Jin-Ping Lai
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
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11
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Amir AZ, Ling SC, Naqvi A, Weitzman S, Fecteau A, Grant D, Ghanekar A, Cattral M, Nalli N, Cutz E, Kamath B, Jones N, De Angelis M, Ng V, Avitzur Y. Liver transplantation for children with acute liver failure associated with secondary hemophagocytic lymphohistiocytosis. Liver Transpl 2016; 22:1245-53. [PMID: 27216884 DOI: 10.1002/lt.24485] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/27/2016] [Accepted: 04/30/2016] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening systemic disease, characterized by overwhelming stimulation of the immune system and categorized as primary or secondary types. Occasionally, acute liver failure (ALF) may dominate the clinical presentation. Given the systemic nature of HLH and risk of recurrence, HLH is considered by many a contraindication to liver transplantation (LT). The aim of this study is to review our single-center experience with LT in children with secondary HLH and ALF (HLH-ALF). This is a cross-sectional, retrospective study of children with secondary HLH-ALF that underwent LT in 2005-2014. Of 246 LTs, 9 patients (3 males; median age, 5 years; range, 0.7-15.4 years) underwent LT for secondary HLH-ALF. Disease progression was rapid with median 14 days (range, 6-27 days) between first symptoms and LT. Low fibrinogen/high triglycerides, elevated ferritin, hemophagocytosis on liver biopsy, and soluble interleukin 2 receptor levels were the most commonly fulfilled diagnostic criteria; HLH genetic studies were negative in all patients. Immunosuppressive therapy after LT included corticosteroids adjusted to HLH treatment protocol and tacrolimus. Thymoglobulin (n = 5), etoposide (n = 4), and alemtuzumab (n = 2) were used in cases of recurrence. Five (56%) patients experienced HLH recurrence, 1 requiring repeat LT, and 3 died. Overall graft and patient survival were 60% and 67%, respectively. Six patients are alive and well at a median of 24 months (range, 15-72 months) after transplantation. In conclusion, LT can be beneficial in selected patients with secondary HLH-ALF and can restore good health in an otherwise lethal condition. Liver Transplantation 22 1245-1253 2016 AASLD.
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Affiliation(s)
- Achiya Z Amir
- Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Simon C Ling
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Naqvi
- Haematology and Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Weitzman
- Haematology and Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Annie Fecteau
- General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Grant
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nadya Nalli
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ernest Cutz
- Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Binita Kamath
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Nicola Jones
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Maria De Angelis
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vicky Ng
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
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12
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Tannuri ACA, Porta G, Kazue Miura I, Santos MM, Moreira DDAR, de Rezende NMA, Miyatani HT, Tannuri U. Pediatric acute liver failure in Brazil: Is living donor liver transplantation the best choice for treatment? Liver Transpl 2016; 22:1006-13. [PMID: 26946330 DOI: 10.1002/lt.24435] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 02/04/2016] [Accepted: 02/07/2016] [Indexed: 02/07/2023]
Abstract
Acute liver failure (ALF) in children is a life-threatening condition that often leads to urgent liver transplantation (LT). The aim of the present investigation was to describe the experience in Brazil in treating pediatric ALF, with an emphasis on the role of living donor liver transplantation (LDLT) in treating this condition. All children with ALF who fulfilled the criteria for an urgent LT were admitted to the intensive care unit. Patients were divided into 2 groups based on the moment of admission: before and after June 2007, when the LDLT program for ALF was started. Statistical analyses were performed to identify prognostic factors of patients with ALF. For the study, 115 children with ALF were admitted. All patients had some degree of encephalopathy. Among the patients, 26% of them required intracranial pressure monitoring (IPM), 12.8% of the patients required hemodialysis, and 79 patients underwent transplantation (50 deceased donors and 29 living donors) corresponding to 12.4% of all pediatric LTs. Only 9 children recovered without LT. The need for IPM and nonperformance of LT were related to a higher mortality. The mortality rate of patients who underwent LT was significantly lower than that of children with ALF who did not undergo a LT (48.1% versus 75%; P = 0.02). The incidences of primary nonfunction and mortality were statistically higher among deceased donor liver transplantations than LDLTs. Finally, it was verified that the overall survival rate of transplanted patients was increased after the introduction of LDLT (P = 0.02). In conclusion, ALF in children continues to be a severe and devastating condition, and a LT should be performed promptly. The introduction of LDLT could increase the survival rate of patients in Brazil. Liver Transplantation 22 1006-1013 2016 AASLD.
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Affiliation(s)
| | - Gilda Porta
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | - Irene Kazue Miura
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | - Maria Merces Santos
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | | | | | - Helena Thie Miyatani
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | - Uenis Tannuri
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
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