Acute liver failure (ALF) in the setting of suspected herpes simplex virus (HSV) or varicella zoster virus (VZV) infection is a time-critical presentation. Clinical features suggestive of herpetic or zoster infection alongside hepatic failure — particularly when accompanied by encephalopathy — require immediate management decisions that cannot wait for laboratory confirmation alone.
Patients presenting with ALF and encephalopathy who show features suggestive of HSV or VZV infection represent a subset where prompt clinical action is essential. Confirmatory viral PCR testing should be obtained, but the time-sensitive nature of this scenario means treatment initiation precedes results.
Empiric intravenous antiviral therapy is initiated promptly upon clinical suspicion and continued pending confirmatory viral PCR testing. Early initiation offers the best chance of a favourable outcome. The complete protocol — including agent selection, monitoring parameters, and transition criteria — is available in the structured regimen below.
DOI: 10.14309/ajg.0000000000002340
Early antiviral therapy with IV acyclovir is indicated if HSV infection is suspected because this offers the best chance for a good outcome.
In patients presenting with ALF, grade 2 encephalopathy and features suggestive of HSV or zoster infection, we suggest empiric treatment with IV acyclovir until confirmatory testing with viral PCR is obtained.
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