Case Presentation

Acute liver failure associated with severe dengue in a young adult with obesity

Insuficiencia hepática aguda asociada al dengue grave en un adulto joven con obesidad

Nguyen Bui Thai Huy^1,2 https://orcid.org/0009-0003-6881-7578
Tran Quang Khai¹ https://orcid.org/0000-0002-7840-7818
Tran Hoang Phuong^1,2 https://orcid.org/0009-0006-3340-3414
Ho Nguyen Tra Uyen^1,2 https://orcid.org/0009-0002-4192-5811
Ma Thai Nguyen¹ https://orcid.org/0009-0003-7890-7606
Le Khanh Toan² https://orcid.org/0009-0006-7767-4523
Nguyen Duy Linh^1* https://orcid.org/0000-0001-8283-9237

¹Can Tho University of Medicine and Pharmacy. Can Tho City, Vietnam.
²Can Tho Central General Hospital. Can Tho City, Vietnam.

*Author for correspondence. Email: ndlinh@ctump.edu.vn

ABSTRACT

Background: Severe dengue can lead to multiorgan dysfunction, among which acute liver failure (ALF) is a rare but life-threatening complication.
Objective: To present a rare case of ALF associated with severe dengue in a young adult with obesity.
Clinical Case: A 19-year-old obese male college student (BMI 33 kg/m²) who was admitted with persistent high-grade fever for 4 days, headache, myalgia, and vomiting. He was diagnosed with severe dengue presenting with shock, severe hepatic involvement complicated by ALF, sepsis, and respiratory failure. Laboratory findings revealed markedly elevated transaminases (AST 4686 U/L, ALT 1231 U/L), total/direct bilirubin of 91/55 µmol/L, INR of 1.92, serum ammonia of 272 µg/dL, and blood lactate of 8.3 mmol/L. The patient was managed intensively with high-flow nasal cannula oxygen therapy, plasma exchange, L-ornithine L-aspartate infusion, intravenous meropenem, and supportive care in the intensive care unit. His condition gradually improved, with resolution of hepatic and respiratory dysfunction, and he was discharged in stable condition after 10 days of illness.
Conclusion: Acute liver failure can occur in the course of severe dengue, particularly in patients with risk factors such as obesity. Early recognition and aggressive management are essential for improving clinical outcomes.

Keywords: acute liver failure; obesity; plasma exchange; severe dengue.

RESUMEN

Antecedentes: El dengue grave puede provocar disfunción multiorgánica. Una complicación poco frecuente pero potencialmente mortal es la insuficiencia hepática aguda (IHA).
Objetivo: Presentar un caso raro de IHA asociada con dengue grave en un adulto joven con obesidad.
Caso Clínico: Estudiante universitario, masculino, 19 años de edad, obeso (IMC 33 kg/m²). Ingresó con fiebre alta persistente durante 4 días, cefalea, mialgias y vómitos. Se diagnosticó con dengue grave, con shock, afectación hepática grave, complicada por IHA, sepsis e insuficiencia respiratoria. Exámenes de laboratorio: Elevación marcada de transaminasas (AST 4686 U/L, ALT 1231 U/L), bilirrubina total/directa en 91/55 µmol/L, INR en 1,92, amoníaco sérico en 272 µg/dL y lactato sanguíneo en 8,3 mmol/L. Se trató de manera intensiva con oxigenoterapia mediante cánula nasal de alto flujo, recambio plasmático, infusión de L-ornitina L-aspartato, meropenem i.v. y cuidados de soporte, en la unidad de cuidados intensivos. Mejoró gradualmente, con resolución de la disfunción hepática y respiratoria. Egresó en condición estable después de 10 días de enfermedad.
Conclusión: La IHA puede presentarse en el curso del dengue grave, especialmente en pacientes con factores de riesgo como la obesidad. El reconocimiento temprano y el manejo intensivo son esenciales para mejorar el pronóstico clínico.

Palabras clave: dengue grave; insuficiencia hepática aguda; obesidad; recambio plasmático.

Received: 22/07/2025
Approved: 08/10/2025

INTRODUCTION

Dengue fever is an infectious disease caused by the dengue virus and transmitted by Aedes mosquitoes. While most cases follow a self-limiting course, a small proportion may progress to severe dengue, characterized by plasma leakage, shock, severe bleeding, and organ dysfunction. Among these complications, acute liver failure (ALF) is a rare but potentially fatal condition if not promptly recognized and managed.^(1,2,3) Its occurrence in young adults with obesity is particularly uncommon, highlighting the need to consider host metabolic factors when assessing disease severity.

The objective of this report is to present a rare case of acute liver failure associated with severe dengue in a young adult with obesity, aiming to provide insights that may support early recognition and management of similar high-risk patients.

CLINICAL CASE

A 19-year-old male college student with class I obesity (BMI 33 kg/m²), no prior liver disease, and no hepatotoxic drug use was admitted on illness day 4, with persistent high-grade fever, headache, myalgia, vomiting, and anorexia.

He was diagnosed with dengue fever with warning signs. Initial labs revealed positive NS1 antigen, platelets 38 × 10⁹/L, hematocrit 47.1%, AST 720 U/L, and ALT 490 U/L. By midday, he developed compensated shock (BP 100/80 mmHg, HR 140 bpm, CRT ≈ 2 s, Hct 47.3%) and responded well to fluid resuscitation with normal saline at 15 mL/kg/h.

On illness day 5, after 24 hours of stable hemodynamics, fluids were discontinued. Later that day, labs showed evidence of acute liver failure: AST 4686 U/L, ALT 1231 U/L, PT 42%, INR 1.92, ammonia 213 μg/dL, and lactate 8.3 mmol/L. Chest X-ray revealed left-sided pneumonia and abdominal ultrasound showed mild ascites. He was transferred to the ICU with a diagnosis of severe dengue complicated by ALF in the post-shock phase, concurrent sepsis, and respiratory failure.

Management included high-flow nasal cannula oxygen, daily plasma exchange (1–1.5 plasma volumes), i.v meropenem (1 g every 8 hours), L-ornithine L-aspartate (10 g/day), platelet transfusions (2 units/day), vitamin K1 (10 mg/day), and i.v. albumin 20% (100 mL/day).

By illness day 8, the patient improved significantly with normalization of liver function and coagulation, resolution of respiratory symptoms, and oxygen discontinuation. He was discharged on day 10 in stable condition. Laboratory trends are summarized in table 1.

Ethical considerations

Written informed consent was obtained from the patient for publication of this case report.  

COMMENTS

Hepatic involvement in dengue infection

Liver injury is a common feature of dengue, though ALF remains rare and typically occurs in severe forms such as shock, severe bleeding, or multiorgan dysfunction.^(4,5,6) In another study of 1926 dengue patients, 13.3% had moderate to severe liver injury, while ALF was observed in only 0.31%⁽³⁾. Nguyen QT et al.⁽¹⁾ reported ALF in 24.2% of 178 patients with AST/ALT ≥ 1000 U/L. Leowattana W et al.⁽⁷⁾ found hepatocellular injury in up to 90% of dengue cases, with ALF-related mortality rates ranging from 20% to 68.3% despite its low incidence (0.31–1.1%). In current case, the patient had AST/ALT of 4686/1231 U/L, total bilirubin 91 µmol/L, prolonged PT, elevated ammonia, and a MELD score of 19—fulfilling criteria for ALF.

Pathophysiology of dengue-associated ALF

The pathogenesis of liver dysfunction in dengue is multifactorial. Proposed mechanisms include direct viral cytopathic effects on hepatocytes, dysregulated host immune responses leading to immunopathology, ischemic hepatic injury due to hypoperfusion in dengue shock syndrome, or a combination of these factors.^(8,9,10) In this case, several contributing risk factors for ALF were identified: Dengue shock, secondary bacterial infection (as suggested by an elevated procalcitonin level of 1.75 ng/mL), hyperammonemia, and obesity.

Role of obesity in disease prognosis

The patient had a BMI of 33 kg/m², corresponding to class I obesity. Obesity has been recognized as an independent risk factor for increased disease severity in dengue infection.⁽¹¹⁾ Beyond epidemiological observations, several pathophysiological mechanisms may underlie this association. Obesity induces chronic low-grade inflammation, alters cytokine balance (elevated IL-6, TNF-α), and causes hepatic steatosis and insulin resistance, which may sensitize hepatocytes to viral and hypoxic injury. These metabolic derangements amplify immune dysregulation and oxidative stress, potentially worsening hepatic necrosis in severe dengue.^(11,12,13)

Therapeutic approach: N-Acetylcysteine and plasma exchange

N-acetylcysteine (NAC) mitigates oxidative stress by replenishing glutathione, scavenging free radicals, enhancing hepatic perfusion, and reducing inflammation. It has demonstrated clinical benefits in dengue-associated ALF. Shrestha DB et al.⁽¹⁴⁾ reported that NAC use in patients with ALF resulted in a 53% lower mortality rate compared to standard care. However, intravenous NAC was unavailable in this case, and high-volume plasma exchange (HVPE) was used as an alternative. HVPE may reduce the inflammatory burden in ALF by removing cytokines and damage-associated molecular patterns.⁽¹⁵⁾

Both European Association for the Study of the Liver (2017)⁽¹⁶⁾ and the American Society for Apheresis (2019)⁽¹⁷⁾ recommend early HVPE in ALF management. In Asia, plasma exchange and NAC are increasingly adopted for dengue-related ALF.^(18,19) Alternative therapies such as continuous renal replacement therapy or Molecular adsorbent recirculating system may also improve detoxification in ALF, but are less accessible in low-resource settings. Although plasma exchange was temporally associated with rapid improvement in this case, causality cannot be conclusively established, and recovery could have been aided by intensive supportive measures (hemodynamic stability, oxygenation, and infection control). Nonetheless, early HVPE remains a promising adjunctive therapy, particularly where NAC or liver transplantation are unavailable.

Acute liver failure can occur in the course of severe dengue, particularly in patients with risk factors such as obesity. Early recognition and aggressive management are essential for improving clinical outcomes.

Acknowledgements

We sincerely acknowledge the valuable support and enthusiastic assistance of Can Tho University of Medicine and Pharmacy and Can Tho Central General Hospital throughout the management and reporting of this case.

BIBLIOGRAPHIC REFERENCES

1. Nguyen QT, Pham NH, Pham KO, Nguyen LTN. Severe dengue hemorrhagic fever with severe liver injury: clinical, laboratory findings and treatment with N-acetylcysteine [Internet]. Vietnam Med J. 2025;549(2):46-50. DOI: 10.51298/vmj.v549i2.13752

2. Wongtrakul W, Charatcharoenwitthaya K, Karaketklang K, Charatcharoenwitthaya P. Incidence of acute liver failure and its associated mortality in patients with dengue infection: A systematic review and meta-analysis [Internet]. J Infect Public Health. 2024;17(8):102497. DOI: 10.1016/j.jiph.2024.102497

3. Mon KK, Nontprasert A, Kittitrakul C, Tangkijvanich P, Leowattana W, Poovorawan K. Incidence and Clinical Outcome of Acute Liver Failure Caused by Dengue in a Hospital for Tropical Diseases, Thailand [Internet]. Am J Trop Med Hyg. 2016;95(6):1338. DOI: 10.4269/ajtmh.16-0374

4. Chia PY, Thein TL, Ong SWX, Lye DC, Leo YS. Severe dengue and liver involvement: an overview and review of the literature [Internet]. Expert Rev Anti Infect Ther. 2020;18(3):181–9. DOI: 10.1080/14787210.2020.1720652

5. Campana V, Inizan C, Pommier JD, Menudier LY, Vincent M, Lecuit M, et al. Liver involvement in dengue: A systematic review [Internet]. Rev Med Virol. 2024;34(4):e2564. DOI: 10.1002/rmv.2564

6. Nguyen RN, Lam HT, Phan HV. Liver Impairment and Elevated Aminotransferase Levels Predict Severe Dengue in Vietnamese Children [Internet]. Cureus. 2023;15(10):e47606. DOI: 10.7759/cureus.47606

7. Leowattana W, Leowattana T. Dengue hemorrhagic fever and the liver [Internet]. World J Hepatol. 2021;13(12):1968–76. DOI: 10.4254/wjh.v13.i12.1968

8. Seneviratne SL, Malavige GN, de Silva HJ. Pathogenesis of liver involvement during dengue viral infections [Internet]. Trans R Soc Trop Med Hyg. 2006;100(7):608–14. DOI: 10.1016/j.trstmh.2005.10.007

9. Tan SS, Bujang MA. The clinical features and outcomes of acute liver failure associated with dengue infection in adults: a case series [Internet]. Braz J Infect Dis. 2013;17(2):164–9. DOI: 10.1016/j.bjid.2012.09.007

10. Dalugama C, Gawarammana IB. Dengue hemorrhagic fever complicated with acute liver failure: a case report [Internet]. J Med Case Reports. 2017;11(1):341. DOI: 10.1186/s13256-017-1510-1

11. Chiu YY, Lin CY, Yu LS, Wang WH, Huang CH, Chen YH. The association of obesity and dengue severity in hospitalized adult patients [Internet]. J Microbiol Immunol Infect. 2023;56(2):267–73. DOI: 10.1016/j.jmii.2022.08.008

12. Chen CY, Chiu YY, Chen YC, Huang CH, Wang WH, Chen YH, et al. Obesity as a clinical predictor for severe manifestation of dengue: a systematic review and meta-analysis [Internet]. BMC Infect Dis. 2023;23:502. DOI: 10.1186/s12879-023-08481-9

13. Zulkipli MS, Dahlui M, Jamil N, Peramalah D, Wai HVC, Bulgiba A, et al. The association between obesity and dengue severity among pediatric patients: A systematic review and meta-analysis [Internet]. PLoS Negl Trop Dis. 2018;12(2):e0006263. DOI: 10.1371/journal.pntd.0006263

14. Shrestha DB, Budhathoki P, Sedhai YR, Adhikari A, Poudel A, Aryal B, et al. N-acetyl cysteine versus standard of care for non-acetaminophen induced acute liver injury: a systematic review and meta-analysis [Internet]. Ann Hepatol. 2021. DOI: 10.1016/j.aohep.2021.100340

15. Chris-Olaiya A, Kapoor A, Ricci KS, Lindenmeyer CC. Therapeutic plasma exchange in liver failure [Internet]. World J Hepatol. 2021;13(8):904–15. DOI: 10.4254/wjh.v13.i8.904

16. Lampertico P, Agarwal K, Berg T, Buti M, Janssen HLA, Papatheodoridis G, et al. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection [Internet]. J Hepatol. 2017;67(2):370–98. DOI: 10.1016/j.jhep.2017.03.021

17. Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue [Internet]. J Clin Apheresis. 2019;34(3):171–354. DOI: 10.1002/jca.21705

18. Thanh NT, Dat NT, Thinh TN, Phuong NTM, Thanh MTH, Bao NT, et al. Therapeutic plasma exchange and continuous renal replacement therapy in pediatric dengue-associated acute liver failure: A case series from Vietnam [Internet]. Transfus Apher Sci [Internet]. 2023;62(2): 103617. DOI: 10.1016/j.transci.2022.103617

19. Nizhu LN, Anam AM, Huq SMR, Rabbani R, Jahan A, Roy K. Therapeutic plasma exchange in expanded dengue patients having acute liver failure: A case series [Internet]. Trop Doct. 2025; 55(1):51–3. DOI: 10.1177/00494755241286564

Conflicts of interest

The authors declare no conflicts of interest.

Financial Support

None.

Data Availability Statement

The data used to present the case corresponds to Can Tho Central General Hospital, Vietnam.