Fulminant Hepatic Failure in Dengue Infection: Two Survivors From a Resource-Limited Outbreak in Sudan

Dengue is a leading cause of viral hemorrhagic fever globally, with hepatic involvement being common but usually mild. Rarely, dengue can progress to fulminant hepatic failure, a life-threatening complication requiring prompt recognition especially in resource-limited settings. We report two Sudanese male patients (aged 29 and 18) who presented with jaundice, markedly elevated liver enzymes, hepatic encephalopathy, and coagulopathy. Both fulfilled criteria for fulminant hepatic failure with hepatic encephalopathy. One patient had concurrent hepatitis B infection and developed acute kidney injury requiring hemodialysis. Both patients received supportive management including intravenous N-acetylcysteine, correction of coagulopathy, glucose infusion, hypertonic saline, lactulose/rifaximin, and appropriate transfusions. Renal replacement therapy was initiated in the patient with acute kidney injury. Despite severe presentation and limited resources, both patients demonstrated progressive clinical and biochemical improvement. Follow-up showed complete recovery of liver and renal parameters. These cases underscore that early recognition and intensive supportive management, including N-acetylcysteine, are critical for survival in dengue-associated fulminant hepatic failure, even in constrained settings.