Liver Dysfunction in Severe Sepsis from Respiratory Syncytial Virus

Abstract

A 1-month-old child was admitted at our pediatric intensive care unit (PICU) in a very critical state with generalized cyanosis, grunting, high fever, tachypnea, tachycardia, severe hypotension with capillary refill time > 5 seconds, and no palpable pulse. The child was apparently doing well until a few hours before admission. On admission to PICU, his clinical diagnosis was consistent with severe sepsis with his sequential organ failure assessment scores of 7 to 8 points. We started rapid restoration of circulation with aggressive volume replacement and empiric antimicrobial therapy. Despite optimal supportive therapy, the patient showed severe liver injury leading to liver failure, making the treatment more challenging. His simplex real-time reverse transcriptase polymerase chain reaction assay and enzyme linked immune sorbent assay documented respiratory syncytial virus (RSV) infection. Through our case report we would like to highlight the extrapulmonary manifestations of RSV infections and the importance of liver dysfunction during sepsis.

Keywords

sepsis - RSV - liver dysfunction

• References

• 1 Kirin BK, Topić RZ, Dodig S. Hepatitis during respiratory syncytial virus infection--a case report. Biochem Med (Zagreb) 2013; 23 (01) 112-116
• 2 Eisenhut M. Extrapulmonary manifestations of severe respiratory syncytial virus infection--a systematic review. Crit Care 2006; 10 (04) R107
• 3 Eisenhut M, Thorburn K. Hepatitis associated with severe respiratory syncytial virus-positive lower respiratory tract infection. Scand J Infect Dis 2002; 34 (03) 235
• 4 Eisenhut M, Thorburn K, Ahmed T. Transaminase levels in ventilated children with respiratory syncytial virus bronchiolitis. Intensive Care Med 2004; 30 (05) 931-934
• 5 Al-Maskari N, Mohsin J, Al-Maani A, Al-Macki N, Al-Ismaili S. Atypical presentation of respiratory syncytial virus infection. Sultan Qaboos Univ Med J 2016; 16 (01) e86-e91 . Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746050/
• 6 Njoku DB, Kliegman RM. Atypical extrapulmonary presentations of severe respiratory syncytial virus infection requiring intensive care. Clin Pediatr (Phila) 1993; 32 (08) 455-460
• 7 Ng YT, Cox C, Atkins J, Butler IJ. ; NG YT. Encephalopathy associated with respiratory syncytial virus bronchiolitis. J Child Neurol 2001; 16 (02) 105-108
• 8 Thompson MG, Hunt DR, Arbaji AK. , et al; IRIS Network. Influenza and respiratory syncytial virus in infants study (IRIS) of hospitalized and non-ill infants aged <1 year in four countries: study design and methods. BMC Infect Dis 2017; 17 (01) 222
• 9 Singer M, Deutschman CS, Seymour CW. , et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315 (08) 801-810
• 10 Yan J, Li S, Li S. The role of the liver in sepsis. Int Rev Immunol 2014; 33 (06) 498-510
• 11 Wang D, Yin Y, Yao Y. Advances in sepsis-associated liver dysfunction. Burns Trauma 2014; 2 (03) 97-105
• 12 Bernal W. The liver in systemic disease: sepsis and critical illness. Clin Liver Dis 2016; 7 (04) 88-91
• 13 Minemura M, Tajiri K, Shimizu Y. Liver involvement in systemic infection. World J Hepatol 2014; 6 (09) 632-642
• 14 Brienza N. Pathophysiology of Liver Dysfunction in Sepsis. Sepsis and Organ Dysfunction. Available at: https://link.springer.com/chapter/10.1007/978-88-470-2284-3_11 . Accessed May 14, 2017
• 15 Marshall JC. New translational research provides insights into liver dysfunction in sepsis. PLoS Med 2012; 9 (11) e1001341
• 16 Kramer L, Jordan B, Druml W, Bauer P, Metnitz PG. ; Austrian Epidemiologic Study on Intensive Care, ASDI Study Group. Incidence and prognosis of early hepatic dysfunction in critically ill patients--a prospective multicenter study. Crit Care Med 2007; 35 (04) 1099-1104
• 17 Nesseler N, Launey Y, Aninat C, Morel F, Mallédant Y, Seguin P. Clinical review: the liver in sepsis. Crit Care 2012; 16 (05) 235
• 18 Santhanam S, Steele RW. Pediatric sepsis. Available at: http://emedicine.medscape.com/article/972559-overview . Accessed May 14, 2017
• 19 Sepsis and children. Available at: http://www.sepsis.org/sepsis-and/children/ . Accessed May 14, 2017
• 20 Krilov L, Steel R. Respiratory syncytial virus infection. Available at: http://emedicine.medscape.com/article/971488-overview . Accessed June 3, 2017
• 21 Piedra PA, Stark AR. Bronchiolitis (and RSV) in infants and children (Beyond the Basics). Available at: https://www.uptodate.com/contents/bronchiolitis-and-rsv-in-infants-and-children-beyond-the-basics . Accessed May 20, 2017
• 22 Respiratory syncytial virus (RSV). 2013. Available at: http://kidemergencies.com/rsv.html
• 23 Openshaw PJM, Tregoning JS. Immune responses and disease enhancement during respiratory syncytial virus infection. Clin Microbiol Rev 2005; 18 (03) 541-555
• 24 Dahn MS, Lange P, Lobdell K, Hans B, Jacobs LA, Mitchell RA. Splanchnic and total body oxygen consumption differences in septic and injured patients. Surgery 1987; 101 (01) 69-80
• 25 Lautt WW. Mechanism and role of intrinsic regulation of hepatic arterial blood flow: hepatic arterial buffer response. Am J Physiol 1985; 249 (5 Pt 1): G549-G556
• 26 Levy MM, Fink MP, Marshall JC. , et al; SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31 (04) 1250-1256
• 27 Fuhrmann V, Kneidinger N, Herkner H. , et al. Hypoxic hepatitis: underlying conditions and risk factors for mortality in critically ill patients. Intensive Care Med 2009; 35 (08) 1397-1405