A Young Man Dying Of Fulminant Hepato-Renal Syndrome The Tagging To Alcohol Addiction Obscured the Diagnosis and Precluded the Treatment of Chronic Viral Hepatitis (HBV, HCV, HDV) As the Cause of His Liver Cirrhosis

Authors: Kari Syrjänen, Pentti Sipponen, Matti Härkönen, Hannes Tamm

Discourse: The present report describes a 47-year-old man who was referred to hospital due to liver cirrhosis and acute hepatorenal syndrome (HRS) that rapidly progressed, and of which he died within two months. As a result of a sequence of unfortunate events in his management, including an inaccurate and in part erroneous record of the patient’s past history, alcohol was considered as the sole cause of the liver failure (ALD), importantly, without taking a liver biopsy. The patient was ranked outside curative therapy, including renal replacement therapy (RRT) as the bridge to eventual liver transplantation. Instead, he received two courses of corticosteroids (for ALD). The negative serology for hepatitis viruses was not controlled, until in the other hospital during the final days before death, when the patient tested positive for HBV (HBsAb). Autopsy: At autopsy, the liver was large (2.800 g) with micronodular cirrhosis but no typical signs of ALD. When examined using immunohistochemistry (IHC), liver cells were extensively loaded with HBV, HCV and HDV, implicating an activation of a latent chronic viral hepatitis during the hospitalization, and massive replication of all three hepatotrophic viruses. This activation, remaining unnoticed by the clinicians, obviously resulted in acute-on-chronic fulminant viral hepatitis with rapid and fatal liver failure. Conclusions: By labeling the patient’s liver failure as ALD obscured adequate search for other potential causative factors for the patient´s HRS. This is most unfortunate, because standard curative medical treatments (DAA, direct acting antivirals) are available for viral hepatitis, and their diagnosis by biopsy should be straightforward. In contrast, treatment with steroids is contraindicated in viral hepatitis.

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[v1] 2017-08-23 06:40:56

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