Case Presentation: 28 year old male with history of HIV (since 2015, well controlled with last CD4 > 1,000 on Genvoya) presents with non-specific complaints of fevers, chills, headache, nausea and vomiting for several days. He recently traveled to Chicago about two weeks prior to presentation. He was seen at other emergency departments in our area and discharged with recommendations for conservative management, but did not experience improvement in his symptoms. On presentation to our facility he had severe abdominal pain and impressive transaminitis with aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ~ 2,000 units/L as well as total bilirubin of 3.2 mg/dL. Our patient was initially admitted to the floor, but soon deteriorated with a rapid response called for acute, progressive liver injury with mental status changes. He was intubated and uptriaged to the intensive care unit (ICU) requiring vasopressor support. An extensive workup for the etiology of his acute liver failure (ALF) began prior to his ICU admission as well as urgent hepatology consultation for transplant evaluation. This workup included a broad search for autoimmune, viral, thrombotic, and toxin related causes – found to be unremarkable other than a positive Hepatitis A IgM.
Our patient’s condition worsened with severe coagulopathy and worsening liver function with AST/ALT up to 6,000 units/L. He was listed as status 1A and underwent orthotopic liver transplantation on hospital day 4. His surgery went well and was extubated on postoperative day 2. He was discharged home on antiretroviral therapy for his HIV and immunosuppression with Tacrolimus, Prednisone and Mycophenolate. Further history obtained later revealed consumption of shellfish and seafood during his time in Chicago and he is currently active with one male partner. He follows up with hepatology and has done well post-transplantation.

Discussion: Hepatitis A infections are typically seen in the developing world due to its fecal-oral transmission route. However cases have been seen in the US and in person-to-person transmission especially via sexual contact, which remains to be an important risk factor. The vast majority of cases are mild, self-limiting resulting in full recovery. However, there is a small portion of about less than 1 % of cases that progress to ALF. About two-thirds of these patients will have spontaneous survival with supportive measures but the remaining require emergent transplantation. The specific factors why only a small portion of overall cases of acute hepatitis A progress to ALF and the outcomes after transplantation for these patients are not well known or understood.

Conclusions: The rapid progression of acute hepatitis A to a life threatening state is a fairly uncommon clinical course, however one that should always be considered. The rapid recognition and swift diagnostic/management steps taken by the hospital team ultimately resulted with a favorable outcome in our patient.