Tofacitinib
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Fulminant liver failure secondary to Herpes simplex virus-II reactivation: case report A 33-year-old woman developed fulminant liver failure (FLF) secondary to Herpes simplex virus (HSV)-II reactivation during treatment with tofacitinib for rheumatoid arthritis (RA). The woman presented to the emergency room with 1 week history of loss of appetite, abdominal pain and jaundice. She had recently started receiving tofacitinib [dosage and route not stated] for RA within the preceding month prior to index hospitalisation. She had coagulopathy, encephalopathy and acute elevated levels of AST, ALT and total bilirubin. Based on the findings, she was diagnosed with FLF. Laboratory investigations showed body temperature 96°F, pulse rate 92, RR 24, BP 127/81, serum creatinine 1.89 mg/dL, sodium 126 mmol/L and INR 3.7, which subsequently peaked to 4.3 on day 3 of hospitalisation [not all units stated]. Her AST and ALT were found to be at their peak. On day 4 of hospitalisation, her total bilirubin subsequently peaked at 8.4 mg/dL, and Model for End Stage Liver disease (MELD-Na) score was increased to approximately 44 from 35. Additionally, she was found to have grade III–IV hepatic encephalopathy. Due to elevated MELD score, neurologic status and acute renal failure, the assessment for urgent liver transplant candidacy was initiated to include obtaining a transjugular liver biopsy. The woman was then proactively intubated. Additionally, she was prophylactically initiated on continuous renal replacement therapy with a target serum osmolarity of 315, acetylcysteine and aciclovir due to the suspicion of viral aetiology. On hospital day 2, HSV-II PCR came back positive. The initial liver biopsy demonstrated extensive necrosis (about 80%) and numerous HSV-positive degenerating hepatocytes, suggestive of fulminant herpes hepatitis. As her clinical status continued to decompensate, she underwent successful orthoptic liver transplantation (OLT) on hospital day 5. Based on the clinical picture, the reactivation of HSV II secondary to tofacitinib was confirmed. Post OLT, she started receiving methylprednisolone [solumedrol] and tacrolimus. On postoperative day 2, HSV-2 PCR returned negative. Her renal function was still recovering, while she maintained on aciclovir. Repeat liver biopsy showed evidence of mild acute T-cell mediated rejection. Thereafter, she was re-dosed with intermittent boluses of methylprednisolone with carefully monitored tacrolimus levels with complete resolution of mild rejection. Her HSV-2 viraemia was undetectable on POD 51, and aciclovir therapy was maintained. Following intense rehabilitation, she was discharged. Beck J, et al. The first documented case of fulminant liver failure from herpes simplex virus in an immunocompromised patient taking tofacitinib. GastroHep 2: 253-256, No. 803506275 5, Sep 2020. Available from: URL: http://doi.org/10.1002/ygh2.413
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Reactions 10 Oct 2020 No. 1825
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