Viral etiologies of acute liver failure

Table 1 Known viral etiologies of acute liver failure with associated viral genetic material, common symptoms, diagnostic approach, possible treatment options, indication for liver transplant and whether a vaccine is available

Virus	Virus genetic material	Symptoms	Diagnosis	Possible treatment options	Indication for LT evaluation in ALF?	Dedicated vaccine available?
HAV	RNA	Diarrhea, fever, malaise, anorexia, nausea, vomiting, abdominal pain, headache	Serologic	Supportive	Yes	Yes
HBV	DNA	Anorexia, jaundice, abdominal pain, constitutional symptoms	Serologic + viral DNA	Entecavir, tenofovir	Yes	Yes
HCV	RNA	Fatigue, myalgia, low-grade fever, nausea, vomiting, jaundice	Serologic + viral RNA	DAA requires further study in ALF	Yes	No
HDV	RNA	Fatigue, anorexia, lethargy, nausea	Serologic + viral RNA	Requires further study in ALF, demonstrated effectiveness of bulevirtide + peginterferon alfa-2α in chronic HDV	Yes	No
HEV	RNA	Fatigue, anorexia, lethargy, nausea	Viral RNA	Ribavrin, glycyrrhizin	Yes	Yes2
CMV	DNA	Pharyngitis, lymphadenopathy, arthralgia, lymphocytosis, splenomegaly, hepatitis	Serologic + viral DNA	Transplantation in ALF; ganciclovir, valganciclovir, foscarnet and cidofovir in ALI	Yes	No
EBV	DNA	Fever, sore throat, lymphadenopathy, mononucleosis syndrome	Viral DNA	Acyclovir, ganciclovir, famcilovir, valganciclovir +/- corticosteroids	Yes	No
VZV	DNA	Blistering, erythematous rash, “shingles”	Viral DNA	Acyclovir, IVIG1	Yes	Yes
Parvovirus B19	DNA	Erythema infectiosum: Fever, rash, arthralgias	Serologic	IVIG, hydroxyurea, cidofovir/brincidofovir, coumarin	Yes	No
HSV	DNA	Painful oral or genital sore; non-specific systemic symptoms	Serologic + viral DNA	Acyclovir	Yes	No
YF	RNA	Fever, headache, myalgias, nausea	Serologic + viral RNA	Sofosbuvir1	Yes	Yes
SARS-CoV-2	RNA	Upper and/or lower respiratory tract infection, cough, fever, anorexia	Serologic or viral RNA	Supportive	Yes	Yes
DENV	RNA	Fever, headache, body pains, chills, sore throat, rash	Serologic or viral RNA	NAC1	Yes	Yes
HAdV	DNA	Localized upper or lower respiratory tract infection, gastroenteritis	Histologic4	Cidofovir	Yes	Yes3

¹Requires further study.

²Only available in China.

³Only routinely available for military recruits.

⁴May require further testing for human adenovirus speciation.

ALT: Acute liver failure; LT: Liver transplant; HAV: Hepatitis A virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HDV: Hepatitis D virus; HEV: Hepatitis E virus; CMV: Cytomegalovirus; EBV: Epstein-Barr virus; VZV: Varicella zoster virus; HSV: Herpes simplex virus; YF: Yellow fever; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; DENV: Dengue virus; HAdV: Human adenovirus; ALI: Acute liver injury; DAA: Direct-acting antivirals; IVIG: Intravenous immune globulin; NAC: N-acetylcysteine; ALF: Acute liver failure.