Differential diagnosis of acute liver failure in India

Background: Acute liver failure (ALF) is a condition with rapid deterioration of liver function resulting in hepatic encephalopathy and/or coagulopathy in patients with previously normal liver. Complicated forms of certain infectious diseases like falciparum malaria, leptospirosis, dengue fever, ricketsial fever, typhoid fever, haemophagocytosis, herpes simplex virus, cytomegalovirus, tuberculosis or amoebic liver abscess can present with altered mentation and/or bleeding manifestations in presence of jaundice and mimic ALF due to acute viral hepatitis (AVH). Methods: We describe our experience in last 2 years with 28 patients of ALF due to above mentioned conditions (ALF-ID) and compared them with 28 patients with ALF due to AVH (ALF-AVH). Results: In ALF-ID, typhoid fever was present in 1, haemophagocytosis in 1, ricketsial infection in 4 (scrub typhus = 2, endemic typhus = 2), amoebic liver abscess in 4, leptospirosis in 5, dengue fever in 5 and falciparum malaria in 8 patients. In ALF-AVH, hepatitis E and B co-infection was responsible in 1, hepatitis A and E co-infection in 1 and hepatitis E, B and C co-infection in 1, hepatitis E in 18, hepatitis A in 2 and hepatitis B in 5 patients. Differentiation of various forms of ALF-ID from ALF-AVH depends on various clinical, haematological and biochemical parameters, in addition to specific diagnostic tests. Patients with ALF-AVH had mortality rate of 50% (14/28) and ALF-ID had mortality rate of 25% (7/28). Conclusions: In developing countries, ALF-mimicking infections should be looked for in differential diagnosis of ALF. Early identification and treatment of these infections is important in reducing mortality.