Fulminant hepatic failure in measles in a 6-month-old child
A 6-month-old previously healthy female infant was seen in the clinic with a history of 3 days of fever, cold symptoms, conjunctival congestion and dry cough. The child developed a maculopapular rash on day 5 that began on her face and then spread to her entire body. She was clinically diagnosed with measles and treated symptomatically with acetaminophen and vitamin A.

She was brought to the emergency room after 2 days of lethargy, vomiting and decreased oral intake. There was no history of any hepatotoxic drug ingestion. Emergency room evaluation showed dehydration and icteric sclerae, tender liver 4 cm below costal margin with a hemoglobin level 11.4 g/dL, white blood count 11,100/mm3 (66% polymorphs, 28% lymphocytes), serum bilirubin 1.7 mg/dL, direct bilirubin 0.91 mg/dL, aspartate transaminase 7,980 units/L, alanine transaminase 5,120 units/L, blood urea 44 mg/dL, serum creatinine 0.54 mg/dL, prothrombin time 46 s with INR 3.8.

She was admitted to the pediatric ward with a diagnosis of acute liver failure and started on intravenous fluids, vitamin K and other supportive treatment including fresh frozen plasma and N-acetyl cysteine. The workup for cause of liver failure revealed negative results for hepatitis A, B and E screen as well as negative Epstein-Barr and cytomegalovirus.

Her measles antibodies were positive with IgM levels of 37.42 units/mL (lab reference of < 8) and negative IgG of 4.33 units/mL (lab reference of < 8). The ultrasound of the abdomen showed hepatomegaly.

The baby improved on supportive treatment and did not require referral for liver transplantation. At the time of discharge alanine transaminase was 480 U/L, aspartate transaminase was 1,410 U/L, prothrombin time was 15 s with INR of 1.3 and returned to < 45 units/L on follow-up. The child is being followed up on a regular basis and is doing well.

Read more here: http://www.theijcp.org/index.php/ijcp/article/view/294/247