Acute Liver Failure: Is Acetaminophen the Only Culprit?

Epstein-Barr virus (EBV) is a common herpesvirus associated with infectious mononucleosis and rare complications such as hepatitis. EBV-associated hepatitis during acute infection may alter liver metabolism, compounding the risk of drug-induced toxicity. We report the case of a 16-year-old female with acute EBV infection who developed severe acetaminophen toxicity after reported use for migraine relief. Her condition was refractory to N-acetylcysteine but improved with the addition of fomepizole, which may have mitigated liver injury by reducing N-acetyl-p-benzoquinone imine (NAPQI) production via CYP2E1 inhibition and suppressing inflammation. This case underscores the complexity of managing pediatric acute liver failure with coexisting hepatic insults, particularly in the presence of viral infections that disrupt liver metabolism, and highlights fomepizole as a potential adjunct in pediatric N-acetylcysteine-refractory acetaminophen toxicity. Further research is warranted to explore the interactions between viral hepatitis and drug-induced liver injury.