S5531 A Case of Acute Liver Failure Due to Hepatitis C Rescued by Direct-Acting Antivirals

Introduction: We present a rare case of acute liver failure secondary to acute hepatitis C infection in a young woman that was cured by direct-acting antivirals (DAA). Case Description/Methods: A 21-year-old woman with a history of polysubstance use was brought to the Emergency Department for altered mental status and was found to have elevated liver function tests (LFTs). She was suspected to have drug induced liver injury (DILI) and started on intravenous N-acetylcysteine. Her urodynamic study was positive for amphetamines, cocaine, and fentanyl. Mental status changes were initially attributed to her substance use. Unfortunately, her condition continued to worsen, and her aspartate aminotransferase/alanine aminotransferase increased to 7,389/5,360. She also developed a profound coagulopathy with an international normalized ratio of 11.14. At that point, she was diagnosed with acute liver failure (ALF), and continuous renal replacement therapy (CRRT)/plus plasma exchange (PLEX) were initiated in an alternating sequence. Despite this treatment, she did not improve, and her international normalized ratio spiked to 12.19 between PLEX/CRRT sessions. Meanwhile, her hepatitis C virus (HCV) polymerase chain reaction (PCR) showed a viral load of 69.9 M IU/mL with a nonreactive HCV antibody, indicating acute HCV infection, which was suspected to be the cause of her ALF. Treatment with sofosbuvir/velpatasvir was initiated. The viral load decreased to 0.7 M IU/mL 5 days after DAA initiation. Her international normalized ratio started to plateau between PLEX/CRRT sessions, and it dropped below 2 after 6 days of treatment with DAA. Notably, her alpha-fetoprotein, which was 5.9 before initiation of DAA, rose to 1,096 in 5 days, indicating robust liver regeneration. She eventually made full liver function recovery. She showed anti-HCV seroconversion 2 weeks after initial testing. Her mental status did not recover initially in spite of multiple computed tomography heads showing no cerebral edema. LP revealed positive herpes simplex virus-1 (HSV-1) PCR in the cerebrospinal fluid. Of note, her initial liver disease work up had shown negative blood HSV-1 and 2 PCR and hence her liver disease was not thought to be due to HSV. The patient had a prolonged intensive care unit stay but made a full recovery and was discharged from the hospital after an 80-day hospitalization. Discussion: ALF due to HCV infection is extremely rare, with only a few cases reported in the literature. While we initially suspected DILI as the culprit, she did not improve with intravenous N-acetylcysteine, and her international normalized ratio continued to spike between PLEX sessions. Initiation of hepatitis C treatment with DAA resulted in full recovery. Literature review revealed 1 case of hepatitis C-related ALF in the post-liver transplant setting that was cured with prompt initiation of DAA. A systematic review reports 3 other cases of hepatitis C-associated ALF prior to DAAs availability. This case illustrates that full recovery can be achieved with prompt DAA initiation in cases of ALF secondary to hepatitis C.