Fulminant Hepatitis: Symptoms, Causes, And Treatment

Fulminant hepatitis is a relatively uncommon liver condition, with an incidence rate of about 2,000 cases per year in the United States.¹ However, this condition is dangerous and can be life-threatening.

This article covers what fulminant hepatitis is, the symptoms and causes of the condition, and potential treatments and prevention options.

What is fulminant hepatitis?

Fulminant hepatitis, also known as fulminant hepatic failure or acute liver failure, is defined as acute liver damage that results in coagulopathy (issues in blood coagulation that lead to bleeding problems) and encephalopathy (brain issues that alter its functions or structure). 

It happens without any pre-existing liver disease and within a short period of less than eight weeks from noticing the beginning of hepatitis (inflammation of the liver) symptoms, which is often jaundice. 

However, since not all cases fit exactly this criteria of timeframe, two main other classifications have been used:

1) hyperacute liver failure, which manifests within days from the onset of the first symptoms

2) subacute liver failure/subfulminant hepatic failure in those who experienced liver failure and encephalopathy after up to 26 weeks from the first hepatitis symptoms 

Since the progression of this disease can be rapid, with a very high mortality rate of about 60 to 80%, this condition is an emergency that requires urgent medical care as soon as a diagnosis is made.² This ensures that the appropriate treatment options can be administered to prevent further deterioration of the liver and potentially reverse some of the damage that took place. 

Liver functions

The liver is an essential organ within the body. The liver's main function is the production and metabolism of certain chemicals and substances in the body while also secreting bile which carries away waste and breaks down fat during digestion.

The liver also processes blood and breaks down drugs or other nutrients, so they are non-toxic or used within the body. 

Other important liver functions include:

• Producing proteins for blood plasma

• Producing cholesterol and proteins to carry fat throughout the body

• Converting excess glucose into glycogen (to store)

• Clearing the blood of drugs and other toxins 

• Removing bacteria from the bloodstream

• Clearing bilirubin, a compound that makes the eyes and skin turn yellow

Due to these important functions, liver failure can be detrimental to the individual. 

Symptoms of fulminant hepatitis

Several common signs and symptoms of fulminant hepatitis include:

• Jaundice (yellowing of the skin and eyes)

• Pain in the upper right abdomen 

• Loss of appetite

• Diarrhea 

• Nausea and vomiting 

• Sleepiness and excess fatigue 

• Confusion

• Anxiety or irritability

• Coordination or balance problems 

• A swollen belly (ascites)

• Signs of brain edema and increased intracranial pressure (pressure inside the brain), including headache, pulsatile tinnitus, vision changes, high blood pressure, and slow heart rate

• Signs of upper gastrointestinal tract bleeding, including black or bloody stool or vomiting blood

• Tremors 

Since fulminant hepatitis/acute liver failure develops days or weeks after the initial symptoms of hepatitis, it's likely that the individual will notice certain symptoms and signs first, such as nausea, vomiting, diarrhea, fatigue, loss of appetite, and possibly jaundice.

Following this, more severe symptoms will develop that indicate the progression of this condition. 

What is causing fulminant hepatitis?

There can be many causes of fulminant hepatitis. Not all will be directly related to the condition, and several diseases can overlap. However, the two most common causes are drug-induced and viruses. 

Drug-induced fulminant hepatitis

Since one of the functions of the liver is processing drugs and toxins, drug-induced hepatitis can develop. This can, in turn, result in fulminant hepatitis. 

Drug-induced hepatitis is rare but is caused by an over-excessive or harmful amount of vitamins, medicines, or supplements. Sometimes it can be due to excess amounts reaching a toxic level. Other times it reaches levels over a period of time. 

However, in the case of acute liver failure, the cause is due to a sudden excess amount of drugs or certain drug interactions that cause acute and abrupt elevation of the blood plasma level of this medication. This causes injury to the liver as it attempts to metabolize this large volume of the drug.

Various types of medications can cause drug-induced fulminant hepatitis, including:

• Acetaminophen or paracetamol (in fever and pain medications) is the most common cause of drug-induced fulminant hepatitis, accounting for around 50% of all acute liver failure cases in the US.³

• NSAIDs (aspirins and over-the-counter medications)

• Anabolic steroids

• Birth control pills

• Statins 

• Anti-epileptic medications

• Some antibiotics 

• Some herbal medicines (ginseng, kawakawa, pennyroyal oil, chaparral or germander tea)

• Mushroom poisoning (Death cap mushroom)

If you suspect that you or someone else has taken a toxic amount of any drug or a poisonous substance, call 911 immediately or head to the nearest emergency room.

Viruses

Fulminant hepatitis can be caused by certain viruses, including hepatitis A, B, D, or E. 

Hepatitis C would rarely cause acute liver failure, but hepatitis D, especially as a superinfection alongside hepatitis B, is one of the main causes of viral fulminant hepatitis. While in certain endemic areas, hepatitis A and E could account for the majority of all acute liver failure cases.

In many other countries that adopted strong vaccination programs, the prevalence of all viral acute liver failure has reduced drastically, accounting for less than 10% of all cases.

Other viruses that can also cause fulminant hepatitis include cytomegalovirus, herpes simplex virus, Epstein-barr virus, and hemorrhagic fever viruses.

Other causes

Other causes of fulminant hepatitis include:

• Idiopathic (unknown or unidentified cause), which is the second most common cause of fulminant hepatitis in the US (15% of all cases), after acetaminophen

• Cancer

• Autoimmune hepatitis

• Vascular issues such as ischemia or blood clots

How is fulminant hepatitis diagnosed?

The most important step in treating individuals with acute liver failure is to identify the cause, as the management and prognosis of this condition will rely mainly on identifying the cause and possibly reversing its damage. 

Diagnosis of fulminant hepatitis generally involves various steps so that the health professional can distinguish it from other liver conditions, like liver sarcoidosis or cirrhosis. Diagnosis may involve several steps, including:

• A complete drug and medical history. This will show any prescribed or non-prescribed medications, drugs, supplements, or herbs.

• Laboratory tests. These tests will test for acute hepatitis A, B, D, and E viruses to determine whether a virus is a cause. 

• Blood tests, including complete blood analysis and liver function tests

• Physical examination. The doctor will be looking for symptoms, including unexplained bleeding or jaundice. 

• Electroencephalography in some cases to evaluate encephalopathy

• PT/INR measurements 

Fulminant hepatitis treatment

As mentioned above, the most effective way of treating fulminant hepatitis is to identify the cause ASAP and attempt to treat it to prevent further damage and stabilize the condition.

For example, in the case of an acetaminophen (paracetamol) overdose, a certain medication called N-acetylcysteine is administered, preferably within about eight hours of the ingestion. This can sometimes act as an antidote and reverse the toxic effects of excess acetaminophen in the body.

In acute liver failure caused by viruses, oral antiviral nucleosides are given to try to halt the damage being caused by the virus.

At the stage of acute liver failure, survival without intervention can be poor, about less than 25%.⁴ In severe cases, or if the cause can’t be identified and treated, liver transplantation is required and highly recommended. Survival from liver transplantation may lead to a full recovery. 

If you get approved for a liver transplant, your name will go on a list, and you'll have to wait for a donated organ. During a transplant, the surgeon will remove your liver and replace it with a new and healthy liver. 

How to prevent fulminant hepatitis

Since the two main known causes of fulminant hepatitis include drug overdose and viral hepatitis, there are several ways to reduce the risk of developing the condition: 

1. Follow the dosage requirements and exact prescription of all the medications you take. You should talk with your doctor if you are going to take any new medication or supplement or if you take multiple medications or supplements simultaneously. Your doctor can help you avoid any dangerous drug interactions that can lead to toxicity and liver failure.

It's important that you don't take any more than the recommended dose, as this can lead to a drug overdose. This is important for all medications and supplements, particularly if you have any liver or kidney issues (even if minor) or are taking more than one medication at a time.

2. Ensure you are up to date on your vaccines for hepatitis. Also, avoid contact with other people's bodily fluids and blood as it can be transmitted via these.

The lowdown

Fulminant hepatitis is a late-stage liver condition characterized by rapid deterioration of normal liver functions and damage to the liver tissues, which leads to encephalopathy. Causes can vary, but two of the most commonly known ones are viral hepatitis conditions or drug-induced hepatitis, often from an overdose of acetaminophen. 

If you suspect this condition, seeking urgent medical care in the hospital as soon as symptoms develop is essential to the management and prognosis of this condition. This could ensure early treatment and potentially avoid complete liver damage and liver transplant. 

People also ask

What is the most common cause of fulminant hepatitis?

Causes of fulminant hepatitis include infection from certain viruses (including hepatitis A, B, and C), some prescription medications, autoimmune hepatitis, or cancer. However, the most common cause of fulminant hepatitis is usually an overdose of acetaminophen/paracetamol (found in many over-the-counter medications). 

Who is most at risk for hepatitis?

According to the CDC, several factors increase the risk of hepatitis.⁵ These include: 

• People who live in or visit endemic areas, particularly in the case of A and E (as it can be transmitted through ingesting unhygienic food or water that contains feces of an infected person)

• People who use or inject drugs

• Men who have sex with men 

• Sexual transmission with someone with hepatitis

• People with diabetes

• People with HIV/Aids

• Homelessness 

Is fulminant hepatitis fatal?

Fulminant hepatitis can quickly become life-threatening without proper diagnosis or treatment. According to research, the mortality rate of fulminant hepatitis is very high, ranging from 60–80% without liver transplantation, and varies based on the cause and quick access to a good healthcare system.