Falla hepática aguda en pediatría / Pediatric acute liver failure

Resumen: La falla hepática aguda (FHA) es poco frecuente en pediatría, amenaza la vida y requiere aborda je multidisciplinario para su diagnóstico y tratamiento tempranos. El presente artículo tiene como objetivo realizar actualización de definiciones, enfoques y tratamientos disponibles. Los artículos se obtuvieron de la revisión de la literatura disponible entre 2000 y 2020 en varias bases de datos (Pub- med, LILACS, BIREME, Google Académico y UpToDate), empleando términos "acute liver failure" en Pubmed, "pediatric acute liver failure", "falla hepática aguda en pediatría" para otros buscadores y aplicando filtros según edad, fecha de publicación y tipo de estudio (ensayos clínicos, artículos de revisión, revisiones sistemáticas, estudios de casos y controles), se eligieron aquellos artículos con mayor número de citaciones y con datos recientes. La FHA requiere soporte en cuidado intensivo pe diátrico y su diagnóstico temprano favorece la instauración del tratamiento. Se recomienda el enfo que de pruebas diagnósticas específicas por edad en pacientes pediátricos con FHA. No hay consenso acerca de las indicaciones de trasplante hepático en FHA en pediatría.

Abstract: Acute liver failure (ALF) is a rare and life-threatening entity in pediatrics which requires a multidis ciplinary approach for early diagnosis and treatment. The objective of this article is to update defi nitions, management, and available treatments. We obtained the articles by reviewing the literature available between 2000 and 2020 in different databases (Pubmed, LILACS, BIREME, Google Scholar, and UpToDate), using terms such as "acute liver failure" in Pubmed, and in other databases "pedia tric acute liver failure" and "falla hepática aguda en pediatría" using filters such as age, publication date, and types of study (clinical trials, review articles, systematic reviews, and case-control studies). We chose those articles with the highest number of citations and with recent data. The ALF requires support in the pediatric intensive care unit and its early diagnosis favors the beginning of treatment. In pediatric patients with ALF, it is recommended to focus on age-specific diagnostic testing. There is no agreement regarding the liver transplantation in pediatric cases of ALF.

Falla hepática aguda / Acute liver failure

La falla hepática aguda es la pérdida súbita de la función hepática en un corto plazo en un paciente sin enfermedad hepática previa, que se acompaña de coagulopatía y encefalopatía. Es una entidad rara con una incidencia muy baja que afecta especialmente a personas jóvenes. La principal causa en países desarrollados es la toxicidad por acetaminofén, mientras que en los países subdesarrollados son las hepatitis virales. El curso natural de la enfermedad es la progresión rápida a muerte por falla orgánica multisistémica, sepsis o edema cerebral. Después del diagnóstico, los pacientes deben remitirse tempranamente a la unidad de cuidado intensivo y a centros que ofrezcan trasplante hepático. La supervivencia sin trasplante hepático hasta hace pocos años era menor al 15%; sin embargo, en la actualidad puede ser hasta del 50%, dependiendo de la causa, y está relacionada con tratamientos específicos, la disponibilidad de trasplante hepático y una atención óptima en las unidades de cuidados intensivos. El trasplante hepático se constituye en el tratamiento de elección para los pacientes con falla hepática aguda y criterios de mal pronóstico del King's College.

Acute liver failure is the severe short-term liver function impairment in a patient without previous liver disease, which is accompanied by coagulopathy and encephalopathy. It is a rare condition with a very low incidence that affects young people. The leading cause in developed countries is acetaminophen toxicity, while in developing countries is mainly caused by viral hepatitis. The natural course is characterized by a rapid progression to death due to multisystemic organ failure, sepsis, or cerebral edema. After diagnosis, patients must be transferred to the intensive care unit and liver transplantation centers. Survival without liver transplantation until a few years ago was less than 15%; however, currently it can be up to 50% depending on the cause, and it is related to specific treatments, availability of liver transplantation and optimal care in the intensive care units. Liver transplantation is the treatment of choice for patients with acute liver failure and King's College criteria for poor prognosis.

Falla hepática aguda fulminante como manifestación de leucemia de células T del adulto en paciente con infección por HTLV-1 / Acute Liver Failure as Presentation of Adult T-cell Leukemia in an HTLV-1 Patient

La falla hepática aguda es el desarrollo de injuria hepática severa con deterioro de la función de síntesis y encefalopatía. Dentro de la variedad de causas, las infiltraciones neoplásicas representan menos del 0,5%. Presentamos el caso de un paciente varón HTLV1 positivo que debuta con una clínica de hepatitis aguda, siendo posteriormente diagnosticado con diseminación de linfoma/leucemia de células T del adulto. Desafortunadamente el paciente presentó deterioro rápido y progresivo de la función hepática, falleciendo a los pocos días de la hospitalización

Acute liver failure is the development of severe hepatic injury with deterioration of liver synthesis function and encephalopathy. Among all the variety of causes, neoplastic infiltration represents less than 0.5%. We present the case of a male patient with a past medical history of HTLV-1 infection, who reports symptoms of acute hepatitis, being diagnosed with Adult T-cell leukemia/ lymphoma. Unfortunately, the patient had a rapid deterioration and passed away a few days after admission

Hepatitis autoinmune en la edad pediátrica / Autoimmune hepatitis in the pediatric age

Resumen: En pediatría, la hepatitis autoinmune y la colangitis esclerosante son patologías de afección hepática cuyo mecanismo de daño es inmunológico. La hepatitis autoinmune es una enfermedad de etiología desconocida, caracterizada por hepatitis de interfase, hipergammaglobulinemia, autoanticuerpos circulantes y una respuesta favorable a la inmunosupresión. Es una enfermedad eminentemente pediátrica, con una afección prevalente hacia mujeres jóvenes. La terapia debe ser instituida con prontitud para prevenir el deterioro rápido, promover la remisión de la enfermedad y la supervivencia a largo plazo. La falta persistente de respuesta o la falta de adherencia al tratamiento dan como resultado una enfermedad hepática terminal. Los pacientes que desarrollan esta patología, y aquellos con insuficiencia hepática fulminante en el momento del diagnóstico, requerirán trasplante hepático.

Abstract: In pediatrics, autoimmune hepatitis and sclerosing cholangitis are liver disorders with an immunological damage mechanism. Autoimmune hepatitis is a disease of unknown etiology characterized by interface hepatitis, hypergammaglobulinemia, circulating autoantibodies and a favorable response to immunosuppression. It is an eminently pediatric disease with a prevalent condition in young women. Therapy should be instituted promptly to prevent rapid deterioration, promote remission of disease and long-term survival. The persistent lack of response or lack of adherence to treatment results in terminal liver failure; these patients, and those with fulminant hepatic insufficiency at the time of diagnosis, will require liver transplantation.

Síndrome inflamatória de reconstituição imune como causa de hepatite autoimune e insuficiência hepática aguda / Immune reconstitution inflammatory syndrome as a cause of autoimmune hepatitis and acute liver failure

RESUMO A insuficiência hepática aguda é uma síndrome rara com elevada mortalidade e frequentemente reconhecida de forma tardia. Os médicos intensivistas desempenham um papel fundamental na suspeição diagnóstica e no manejo das disfunções múltiplo-orgânicas características desta entidade. A síndrome inflamatória de reconstituição imune é uma entidade que se caracteriza pela piora paradoxal do quadro prévio do paciente, após o início de antirretrovirais, desencadeada contra patógenos presentes no hospedeiro ou autoantígenos. A hepatite autoimune tem sido recentemente descrita como uma destas manifestações autoimunes. Os autores relatam o primeiro caso com evolução à insuficiência hepática aguda e óbito em poucos dias após o desenvolvimento de encefalopatia, revisam os casos de hepatite autoimune descritos e tecem comentários sobre as possibilidades terapêuticas neste contexto.

ABSTRACT Acute liver failure is a rare syndrome with high mortality and is often diagnosed late. Intensivist physicians play fundamental roles in the diagnostic suspicion and the management of the multiple-organic dysfunctions characteristic of this entity. Immune reconstitution inflammatory syndrome is an entity that is characterized by the paradoxical worsening of the patient's previous condition, after the initiation of antiretrovirals, triggered against either pathogens present in the host or autoantigens. Autoimmune hepatitis has recently been described as one of these autoimmune manifestations. The authors report the first case with evolution to acute liver failure and death within a few days after the development of encephalopathy, review the cases of autoimmune hepatitis described and comment on the therapeutic possibilities in this context.

Resultados preliminares de hipotermia tópica do fígado em modelo de isquemia/reperfusão hepática em ratos / Preliminary results of topical hepatic hypothermia in a model of liver ischemia/reperfusion injury in rats

ABSTRACT BACKGROUND Ischemia/reperfusion causes organ damage but it is mandatory in hepatic transplantation, trauma and other complex liver surgeries, when Pringle maneuver is applied to minimize bleeding during these procedures. It is well known that liver ischemia/reperfusion leads to microcirculatory disturbance and cellular injury. In this setting hypothermia is known to reduce oxygen demand, lowering intracellular metabolism. OBJECTIVE: To evaluate the effects of hypothermia in liver ischemia/reperfusion injury, using a new model of topic isolated liver hypothermia. METHODS We used male Wistar rats weighting about 250 grams, kept in ad libitum feeding regime and randomly divided into two groups of nine animals: 1) Normothermic group, rats were submitted to normothermic ischemia of the median and left hepatic lobes, with subsequent resection of right and caudate lobes during liver reperfusion; and 2) Hypothermic group, rats were submitted to liver ischemia under hypothermia at 10°C. Liver ischemia was performed for 45 minutes. The animals were euthanized 48 hours after liver reperfusion for blood and liver tissue sampling. RESULTS The transaminases analyses showed a significant decrease of AST and ALT in Hypothermic group (P<0.01) compared to Normothermic group (1403±1234 x 454±213 and 730±680 x 271±211 U/L, respectively). Histology showed severe necrosis in 50% and mild necrosis in 50% of cases in Normothermic group, but severe necrosis in 10% and mild or absent necrosis 90% of the cases in hypothermic group. CONCLUSION: A simplified model of liver ischemia/reperfusion that simulates orthotopic liver autotransplantion was demonstrated. Topical hypothermia of isolated hepatic lobules showed liver protection, being a viable and practical method for any kind of in vivo liver preservation study.

RESUMO CONTEXTO: A isquemia/reperfusão leva a grave lesão de órgãos, mas ocorre obrigatoriamente no transplante hepático, no trauma e em outras cirurgias hepáticas complexas, quando a manobra de Pringle é aplicada com o intuito de minimizar o sangramento durante os procedimentos. É bem conhecido que a isquemia/reperfusão do fígado leva a distúrbios microcirculatórios e lesões celulares. Neste cenário, a hipotermia é conhecida por reduzir a demanda de oxigênio, diminuindo o metabolismo intracelular. OBJETIVO: Avaliar os efeitos da hipotermia na lesão de isquemia/reperfusão hepática utilizando-se um novo modelo de hipotermia isolada do fígado. MÉTODOS: Utilizaram-se ratos Wistar do sexo masculino com peso aproximado de 250 gramas, mantidos em regime de alimentação ad libitum e divididos aleatoriamente em dois grupos de nove animais: 1) Grupo Normotérmico - os ratos foram submetidos a isquemia normotérmica dos lobos hepáticos mediano e esquerdo, com posterior ressecção dos lobos direito e caudado durante a reperfusão hepática; e 2) Grupo Hipotérmico - os ratos foram submetidos a isquemia hepática sob hipotermia a 10°C. A isquemia hepática foi realizada durante 45 minutos. Os animais foram sacrificados 48 horas após a reperfusão hepática para coleta de sangue e tecido hepático para análise. RESULTADOS: As transaminases AST e ALT apresentaram diminuição significativa no grupo Hipotérmico (P<0,01) em relação ao grupo Normotérmico (1403±1234 x 454±213 e 730±680 x 271±211 U/L, respectivamente). A histologia mostrou necrose grave em 50% e necrose leve em 50% dos casos no grupo Normotérmico, porém, necrose grave em 10% e necrose leve ou ausente em 90% dos casos no grupo Hipotérmico. CONCLUSÃO: Foi demonstrado modelo simplificado de isquemia/reperfusão do fígado que simula o autotrasplante de fígado. A hipotermia tópica dos lóbulos hepáticos isolados mostrou proteção do fígado a ischemia/reperfusão, sendo um método viável e prático para qualquer tipo de estudo de preservação hepática in vivo.

Leucemia linfoblástica aguda con grave alteración hepática como manifestación inicial: presentación de dos casos y revisión de la literatura / Acute lymphoblastic leukemia causing hepatic failure: report of two cases

Hematological diseases may cause acute hepatic failure and are seldom sought. We report two cases illustrating this situation. A 16-year-old male presented with an acute liver failure: a bone marrow biopsy showed complete infiltration with lymphoid type blasts. A flow cytometry confirmed the presence of an acute lymphoblastic leukemia. The patient died days later. A 20-year-old female presented with acute liver failure: due to a pancytopenia, a bone marrow biopsy was performed, which confirmed the presence of an acute lymphoblastic leukemia. Chemotherapy was started immediately. The patient had a favorable evolution.

Insuficiencia hepática aguda neonatal: un desafío diagnóstico / Neonatal acute liver failure: a diagnosis challenge

La insuficiencia hepática aguda durante el período neonatal es una enfermedad rara, muy grave, con elevada mortalidad. Se diferencia clínica y etiológicamente de la insuficiencia hepática aguda del niño mayor y del adulto. La coagulopatía, con un Rango Internacional Normatizado > 3, es el parámetro fundamental para definirla. Las causas más frecuentes son la hepatitis fetal aloinmune, previamente denominada hemocromatosis neonatal, las infecciones virales, las enfermedades metabólicas y la linfohistiocitosis hemofagocítica. Existe un grupo de enfermedades tratables que es necesario diagnosticar con mucha rapidez para brindarles el tratamiento correspondiente. El paciente debe ser derivado precozmente a un centro especializado con disponibilidad de trasplante hepático pediátrico para poder darle esta alternativa terapéutica cuando esté indicada.

Neonatal acute liver failure is a rare, very severe disease with a high rate of mortality. It is clinically and etiologically different from acute liver failure seen in older children and adults. Coagulopathy with an international normalized ratio > 3 is the critical parameter that defines it. The most common causes are fetal alloimmune hepatitis, previously called neonatal hemochromatosis, viral infections, metabolic disorders, and hemophagocytic lymphohistiocytosis. There is a group of treatable diseases that require a very early diagnosis for the prescription of an adequate treatment. Patients should be immediately referred to a specialized facility where pediatric liver transplantation is available to implement such therapeutic alternative, if indicated.

Cardiopulmonary bypass ischemic hepatitis reported in five patients

Abstract Objective: In cardiac surgery, the lung, renal and neurological events are the most frequent complications. Less common, acute liver failure is a serious complication that adds high morbidity, mortality, and costs. Therefore, this communication aimed to retrospectively evaluate five patients who presented, in 2014, severe acute liver failure in the immediate postoperative period. Methods: Retrospective data analysis of patients' medical records that showed severe liver failure has been computed in the medical records of five patients undergoing cardiac surgery at the Hospital da Faculdade de Medicina de Ribeirão Preto – USP in the immediate postoperative period from February 1, 2014 to December 12, 2014. The study selected five males patients, 60 to 67 years old, cardiopulmonary bypass mean time of 101.4 minutes (varying from 80 to 140 minutes), who presented acute perioperative liver failure. Results: The five patients showed an impressive increase of blood transaminase (serum alanine aminotransferase), suggesting acute hepatitis. The evolution of all patients was catastrophic, with severe hemodynamic effects and death. Many studies suggest that systemic hypotension is an important pathogenic factor for ischemic hepatitis. However, our data and previous studies raise the possibility that other yet unknown factors other than hypotension may be part of the pathophysiology of cardiopulmonary bypass after ischemic hepatitis (anticoagulation inadequate for the quality of heparin and protamine, etc.). Conclusion: Currently, there are no conclusive studies on the prevention of perioperative liver failure. More well-designed studies are needed on the introduction and evolution of liver dysfunction after cardiac surgery.

Falência hepática aguda em crianças e adolescentes / Acute liver failure in children and adolescents

A halência hepática aguda (FHA) é uma condição rara, mas devastadora, que evolui para falência de múltiplos órgãos e óbito como seu curso natural. A assistência intensiva e o transplante hepático possibilitaram a modificação da história natural e aumento da sobrevida. A FHA, geralmente, se apresenta em uma criança ou adolescente previamente hígido que inicia com sintomas inespecíficos de duração variada e com a evolução do quadro surgem outros sintomas como icterícia, vômitos, hipoglicemia e convulsões, tornando a síndrome clínica evidente. O diagnóstico etiológico é importante, uma vez que algumas doenças de base possuem tratamentos específicos. Contudo, em até 50% dos casos, um diagnóstico específico não é estabelecido. Sua presença será estabelecida se há evidência bioquímica de falência hepática aguda, na ausência de doença hepática crônica e associada à coagulopatia de origem hepática não corrigível pela vitamina K (RNI > 1,5 em paciente com encefalopatia hepática ou RNI ? 2 na ausência de encefalopatia hepática). O tempo entre o início do quadro clínico e o desenvolvimento da encefalopatia deve ser inferior a oito semanas. O reconhecimento e o encaminhamento para centro especializado devem ser o mais precoce possível. A indicação de transplante hepático deve ser avaliada periodicamente. O tratamento intensivo e multidisciplinar é essencial para sobrevida.

The Acute Liver Failure (ALF) is a rare but devastating condition that can lead to multiple organ failure and death as its natural course. Intensive therapy and liver transplantation have changed its natural history and raised survival rates. ALF usually presents in a previously healthy child who initiates with unspecific symptoms of variable duration and then evolve with jaundice, vomiting, hypoglycemia and seizures, when the clinical syndrome becomes evident. The etiologic diagnosis is importantbecause some diseases have specific treatments. However in 50% of the cases a specific diagnosis is not estabilished. The criteria for diagnosing ALF is biochemical evidence of acute hepatic failure without signs of chronic liver disease associated with coagulopathy non responsive to vitamin K (INR>1,5 with encephalopathy or INR>2 regardless the presence of encephalopathy signs). The time between the initial symptoms and the development of encephalopathy must be less than 8 weeks. Recognizing and referring the patient for a reference center must be a priority. The need for liver transplantation should be periodically assessed. Intensive multidisciplinary care is essential for survival.

Actualización en el diagnóstico y manejo del daño hepático agudo grave en el embarazo / Causes and management of severe acute liver damage during pregnancy

Abnormalities in liver function tests appear in 3% of pregnancies. Severe acute liver damage can be an exclusive condition of pregnancy (dependent or independent of pre-eclampsia) or a concomitant disease. HELLP syndrome and acute fatty liver of pregnancy are the most severe liver diseases associated with pregnancy. Both appear during the third trimester and have a similar clinical presentation. Acute fatty liver may be associated with hypoglycemia and HELLP syndrome is closely linked with pre-eclampsia. Among concomitant conditions, fulminant acute hepatitis caused by medications or virus is the most severe disease. Its clinical presentation may be hyper-acute with neurological involvement and severe coagulation disorders. It has a high mortality and patients should be transplanted. Fulminant hepatic failure caused by acetaminophen overdose can be managed with n-acetyl cysteine. Because of the high fetal mortality rate, the gestational age at diagnosis is crucial.

Prognostic Indicators for Acute Liver Failure Development and Mortality in Patients with Hepatitis A: Consecutive Case Analysis

PURPOSE: Due to the seroepidemiological shift in hepatitis A (HA), its severity, mortality, and complications have increased in recent years. Thus, the aim of this study was to identify predictive factors associated with poor prognosis among patients with HA. MATERIALS AND METHODS: A total of 304 patients with HA admitted to our institution between July 2009 and June 2011 were enrolled consecutively. Patients with complications defined as acute liver failure (ALF) were evaluated, and mortality was defined as death or liver transplantation. RESULTS: The mean age of patients (204 males, 100 females) was 32 years. Eighteen (5.9%) patients had progressed to ALF. Of the patients with ALF, 10 patients (3.3%) showed spontaneous survival while 8 (2.6%) died or underwent liver transplantation. Multivariate regression analysis showed that Model for End-Stage Liver Disease (MELD) and systemic inflammatory response syndrome (SIRS) scores were significant predictive factors of ALF. Based on receiver operating characteristics (ROC) analysis, a MELD > or =23.5 was significantly more predictive than a SIRS score > or =3 (area under the ROC: 0.940 vs. 0.742, respectively). In addition, of patients with a MELD score > or =23.5, King's College Hospital criteria (KCC) and SIRS scores were predictive factors associated with death/transplantation in multivariate analysis. CONCLUSION: MELD and SIRS scores > or =23.5 and > or =3, respectively, appeared to be related to ALF development. In addition, KCC and SIRS scores > or =3 were valuable in predicting mortality of patients with a MELD > or =23.5.

Falência hepática aguda / Acute liver failure

Falência hepática aguda é uma síndrome clínica devastadora, com alta taxa de mortalidade, apesar dos recentes avanços da terapia intensiva. Determinar a causa tem importantes implicações prognósticas, e o transplante de fígado é um tratamento que salva vidas em casos selecionados. O conhecimento das últimas diretrizes e protocolos pode levar a melhores resultados.

Acute liver failure is a devasting clinical syndrome, with high mortality rate, despite critical care advances. Determining the cause has important prognostic implications, and the orthotopic liver transplantation is a life-saving treatment in select cases. Knowledge of the latest guidelines and treatment protocols can lead to improved patient case.

Manejo de la hepatitis B aguda grave y fulminante / Management of acute fulminant hepatitis B

Fulminant hepatitis B virus infection occurs in less than 1percent of acutely infected patients. Acute hepatitis Baccounts for 2-42 percent of the total of fulminant hepatitis cases depending on the geographic area. This infection is associated with 65-93 percent of mortality, without liver transplantation. Its pathogenesis is related to a severe immune response to infected hepatocytes, causing massive cytolysis and liver failure. During the last 3 decades its prognosis has improved due to better medical support in intensive care units, the use of liver transplantation and an improvement in the prevention and management of its complications. More recently the use of liver support devices (MARS, Prometheus, and BAL) has been considered in this situation as a bridge to liver transplantation. Recurrent hepatitis B virus reinfection of the graft was a major issue in the past, but currently with the use of hepatitis B immunoglobulin (HBIg) and oral antiviral therapy, the prognosis has improved, leading to excellent graft and patient outcomes after liver transplantation. There is controversial data on the use of oral antiviral therapy among fulminant hepatitis patients. While some authors have shown beneficial effects, other communications have failed to demonstrate any benefits. Nevertheless, many experts currently recommend the use of oral antiviral therapy in this setting due to their relative safety and potential benefits. This paper reviews the current view on management issues in reference to the patient with fulminant hepatic failure due to acute hepatitis B.

La hepatitis fulminante por virus de hepatitis B ocurre en menos del 1 por ciento de los casos de hepatitis B aguda. Del total de hepatitis fulminantes, entre el 2-42 por ciento son causadas por hepatitis B aguda, dependiendo del lugar geográfico donde se estudia. Se asocia a elevada mortalidad, entre 65-93 por ciento, sin el uso de trasplante hepático. Su patogenia se relaciona a una significativa respuesta inmune a hepatocitos infectados, determinando citolisis masiva y falla hepática. En las últimas 3 décadas el pronóstico de esta patología ha mejorado gracias al soporte médico en unidades de tratamiento intensivo, a la implementación del trasplante hepático, y a la mejoría en la prevención y manejo de sus complicaciones. Más recientemente se ha usado dispositivos de soporte hepático (MARS, Prometheus, BAL), como un puente al trasplante hepático. La reinfección del injerto con hepatitis B era una consideración importante en el pasado, pero con el uso de gamaglobulina específica para hepatitis B y el tratamiento antiviral oral, su pronóstico ha mejorado, determinando un excelente pronóstico del injerto y del paciente a largo plazo post trasplante hepático. Existen datos controversiales referentes al uso de antivirales orales durante una hepatitis fulminante, pues algunos autores muestran beneficios en esta condición, pero otros no han demostrado un beneficio real. Sin embargo, muchos expertos actualmente recomiendan su uso en este escenario, pues son seguros y pueden tener un potencial beneficio. Este artículo revisa el manejo actual del paciente con hepatitis fulminante por hepatitis B aguda.

Celiac artery trunk thrombosis presenting as acute liver failure

Acute mesenteric ischemia is a life-threatening vascular emergency that requires early diagnosis and intervention to adequately restore mesenteric blood flow and to prevent bowel necrosis and patient death. While, almost always superior and inferior mesenteric arteries are involved, we report a 57-year-old male with an unusual celiac artery trunk thrombosis leading to gastero-duodenal and hepato-splenic infarction, and presenting an acute liver failure

Hodgkin's disease with hyperferritinemia, hepatic and heart failure

Diffuse hepatic infiltration is an unusual form of Hodgkin's disease [HD]. Its manifestation as progressive hepatitis or with hepatic failure is even rarer and can be difficult to diagnose. We aim to describe an unusual case of liver failure due to HD. A middle-aged woman with a 10 month history of daily febrile episodes, constitutional symptoms and strikingly high levels of serum ferritin was admitted to our hospital with pancytopenia and jaundice. The patient rapidly deteriorated, and developed hepatic and heart failure. A liver biopsy revealed infiltration of the liver with mixed cellularity type HD that was confirmed by lymph node biopsy. HD must be considered in the differential diagnosis of obstructive jaundice in adults. Liver biopsy early in the course of liver dysfunction may establish this diagnosis without a higher risk of bleeding complications seen once liver failure sets in

Fulminant hepatic failure in an infant with severe dengue infection.

Fulminant hepatic failure due to dengue infection is rare, although mild liver dysfunction is common. Here we report a fatal case of fulminant hepatitis in an infant infected with dengue 3 serotype. Attention must be given to the use of hepatotoxic drugs in some cases of dengue especially in infants.