Acute Liver Failure and Human Herpesvirus 6 Infection: Reactivation in Immunoparesis?

HHV-6 infection is usually asymptomatic or self-limited, although in certain populations, particularly in immunocompromised patients, it can cause serious infections. Hepatic involvement, previously described in immunocompromised and occasionally in immunocompetent adults, can lead to acute liver failure (ALF).

We report a case of a 20-year-old female with no known liver disease, who presented with a 4-day history of diffuse abdominal pain, vomiting, and fever on the first day. She reported an influenza-like syndrome the previous week and undetermined weight loss over the last 2 months, associated with a behavior compatible with a purging eating disorder. She had a binge drinking pattern of alcohol consumption, followed by paracetamol intake for veisalgia, and occasional cannabinoid use. The patient denied other exposures. She developed grade 1 hepatic encephalopathy and was diagnosed with ALF. Further workup for underlying etiology detected HHV-6B, both in peripheral blood and liver tissue.

This ALF has a viral cause due to a possible reactivation of HHV-6 in the context of immunoparesis secondary to malnutrition and binge drinking, though we cannot exclude a contribution from a toxic cause due to paracetamol overuse, facilitated by these same susceptibility factors. HHV-6 should be included in the differential diagnosis of ALF of undetermined cause, particularly in immunocompromised and seriously ill patients.