From hepatitis A to acute liver failure in a resource-limited setting: a case report

Hepatitis A virus (HAV) infection is usually self-limited, but a minority of cases progress to acute liver failure (ALF), particularly, in resource-limited settings. We report a previously healthy 19-year-old woman who presented with 20 days of jaundice, dark urine, and hepatic encephalopathy. Baseline tests showed total bilirubin 18.3 mg/dL, aspartate aminotransferase 281 U/l, alanine aminotransferase 341 U/l, international normalized ratio (INR) 1.23, and positive anti-HAV immunoglobulin M/immunoglobulin G. Although she did not meet formal ALF criteria at presentation, within 72 hours, she progressed to ALF, with bilirubin rising to 28 mg/dL, INR to 1.8, and ammonia to 140 µg/dL; ultrasonography revealed hepatomegaly. In the absence of liver transplantation or continuous renal replacement therapy, a resource-adapted supportive bundle was implemented, including intravenous N-acetylcysteine, vitamin K, neuroprotection, glucose control, early enteral nutrition, conservative transfusion, and infection surveillance. Clinical and biochemical parameters improved, and she was discharged after approximately 4 weeks, with recovery on follow-up. This case highlights early warning signs and the feasibility of a structured non-transplant management pathway for HAV-associated ALF in constrained settings.