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Chapter 232: Infections of the Liver

Grzegorz Telega

INTRODUCTION

Patients with infections of the liver generally present with nonspecific symptoms such as fever, fatigue, abdominal pain, or weight loss. The abdominal pain may be diffuse, be confined to the right upper quadrant, or radiate to the shoulder or back. Other symptoms may include headache, arthralgias, and adenopathy. The initial history should focus on geographic location or travel, unprotected sex or drug use, use of hemodialysis or blood products, other recent exposures, vaccination/immune status, chronicity of symptoms, anatomical anomalies or surgery that may affect the biliary tracts, and family history of hepatitis. Physical exam is often normal; some patients will have right upper quadrant or diffuse abdominal tenderness and hepatomegaly. Jaundice or stigmata of chronic liver disease is infrequent. For additional details regarding viral hepatitis, please refer to Table 232-1 and Chapter 303.

TABLE 232-1COMMON VIRAL INFECTIONS OF THE LIVER AND PRESENTATION
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TABLE 232-1COMMON VIRAL INFECTIONS OF THE LIVER AND PRESENTATION
  Acute Hepatitis Chronic Hepatitis Acute Liver Failure Comments
Hepatotrophic        
HAV ++ – + More common in developing countries; children may be asymptomatic
HBV + +++ + Children may be asymptomatic
HCV + +++ –  
HDV + +++ – Only affects HBV(+) patients, worsens outcome
HEV ++ – + More common in developing countries
DNA        
CMV + + – Affects infants/children more than adolescents/adults
EBV ++ + – Lymphadenopathy; PTLD in immunosuppressed patients
HSV-1, -2 ++ – + Occurs in setting of overwhelming viremia/sepsis
Adenovirus ++ – +  
VZV ++ – + Most often affects immunocompromised patients
HHV 6, 7 ++ – +  
Parvovirus + – + Often causes aplastic anemia simultaneously
RNA        
HIV ++ ++ – Symptoms often due to coinfection
Enterovirus ++ – +  
Measles + – +  
Rubella + – –  
TTV + – –  
Reovirus – + – Possible association with EHBA, cholangiopathy
Parechovirus + – +  
Coronavirus + – –  

(–) unlikely; (+) infrequent to (+++) most likely form of liver involvement for each pathogen.

CMV, cytomegalovirus; DNA , deoxyribonucleic acid; EBV, Epstein-Barr virus; EHBA, extrahepatic biliary atresia; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; HDV, hepatitis D virus; HEV, hepatitis E virus; HHV, human herpesvirus; HIV, human immunodeficiency virus; HSV, herpes simplex virus; PTLD, posttransplant lymphoproliferative disorder; RNA, ribonucleic acid; TTV, transfusion-transmitted virus; VZV, varicella-zoster virus.

Laboratory findings of liver infection often consist of leukocytosis, elevated erythrocyte sedimentation rate (ESR), and variable elevation of bilirubin, aminotransferases (alanine aminotransferase [ALT], aspartate aminotransferase [AST]), alkaline phosphatase, and γ-glutamyl transferase (GGT). Liver ultrasound is useful in initial evaluation of suspected liver infection because it can screen for liver abscess or bile duct anomalies.

BACTERIAL CHOLANGITIS

Cholangitis is an infection of the biliary tracts and is ...

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