A Complex Case of Acute Liver Failure Following Idiosyncratic Drug-Induced Liver Injury, Potentiated by Herpes Simplex Virus Infection.

Acute liver failure (ALF) is a rare, life-threatening condition that may be secondary to drug-induced liver injury (DILI) and certain viral infections. We present the case of a 73-year-old male with a history of fibrotic hypersensitivity pneumonitis with a progressive phenotype, type 2 diabetes mellitus, hypertension, and hyperlipidemia, who was admitted with ALF potentially secondary to DILI. Prior to admission, he was receiving therapy that may be related to idiosyncratic DILI (I-DILI) and ALF, namely nintedanib, which appears to have a most probable relation to I-DILI in this case, considering it was the most recently started drug. Herpes simplex virus (HSV) type 1 was also identified and probably potentiated I-DILI development and ALF. Considering the patient's history and previous medical status, he was not considered eligible for liver transplantation in the setting of a multidisciplinary discussion. Despite therapy with N-acetylcysteine and acyclovir, there was progressive clinical deterioration with worsening of encephalopathy, and the patient died. This case represents a rare and complex situation of ALF following I-DILI potentiated by HSV type 1 infection, reflecting its high mortality risk in patients not undergoing liver transplantation.