Fulminant hepatitis is a rare syndrome of rapid (usually within days or weeks), massive necrosis of liver parenchyma and a decrease in liver size (acute yellow atrophy); it usually occurs after infection with certain hepatitis viruses, alcoholic hepatitis, or drug-induced liver injury (DILI).
(See also Evaluation of the Patient With a Liver Disorder and Overview of Acute Viral Hepatitis.)
Hepatitis B virus is sometimes responsible for fulminant hepatitis, and up to 50% of cases of fulminant hepatitis B involve hepatitis D virus coinfection. Fulminant hepatitis with hepatitis A virus is rare but may be more likely in people with preexisting liver disorders. Occasionally, hepatitis E virus causes fulminant hepatitis, especially in pregnant women, potentially leading to fetal loss, liver failure, and death. The role of hepatitis C virus remains uncertain.
Alcoholic hepatitis may cause fulminant liver failure, but most patients have a long history of heavy drinking and so probably have underlying chronic liver disease.
Drugs (especially ) are the most common cause of fulminant hepatitis in the United States.
Symptoms and Signs of Fulminant Hepatitis
Symptoms of fulminant hepatitis develop and become severe very quickly. Patients rapidly deteriorate because portosystemic encephalopathy develops, progressing to coma and cerebral edema over a period of several days to several weeks. Coagulopathy commonly results from liver failure or disseminated intravascular coagulation, and functional renal failure (hepatorenal syndrome) may develop.
Increasing prothrombin time (PT) or international normalized ratio (INR), portosystemic encephalopathy, and particularly renal failure are ominous.
Diagnosis of Fulminant Hepatitis
Clinical evaluation
Liver tests
PT/INR measurement
Fulminant hepatitis should be suspected if
Patients are acutely ill with new-onset jaundice, rapid changes in mental status, or unexplained bleeding.
Patients with known liver disease rapidly deteriorate.
Laboratory tests to confirm the diagnosis of fulminant hepatitis include liver tests (eg, aminotransferases, alkaline phosphatase) and other tests to evaluate liver function (prothrombin time/international normalized ratio [PT/INR], bilirubin, albumin).
Laboratory tests for acute hepatitis A, B, and C viruses, as well as some other viruses (eg, cytomegalovirus, Epstein-Barr virus, herpes simplex virus), are done to determine whether a virus is the cause.
Complete drug history, including over-the-counter medications and herbal supplements, should be elicited. The serum acetaminophen level should be measured in all patients if is suspected.
Treatment of Fulminant Hepatitis
Oral nucleoside or nucleotide analogs
Sometimes N
Liver transplantation
Meticulous medical care, usually in an intensive care unit, and aggressive treatment of complications improve the outcome of patients with fulminant hepatitis.
If fulminant hepatitis results from hepatitis B, treatment with oral nucleoside or nucleotide analogs can increase the likelihood of survival.
However, emergency liver transplantation provides the best hope for survival. Survival in adults is uncommon without transplantation; children tend to do better.
Patients who survive usually recover fully.
