Cryptogenic Acute Hepatitis: An Enigma – How to Approach?

When the initial evaluation is nondiagnostic, then additional history is essential. AST and ALT levels help guide the evaluation.

Acetaminophen should be strongly suspected with high ALT and AST, recent medicines (antibiotics), supplements, vaccinations.

Test for herpes viruses, COVID-19 and other viruses as clinically indicated. Consider retesting for autoimmune hepatitis (AIH).

Make sure that ferritin is not just an acute phase reactant.

Consider N-acetylcysteine (NAC) with severe hepatitis. If developing acute liver failure, NAC has shown survival benefi t in ALF with Grade 2 HE and should be strongly considered. Refer for liver transplant if appropriate.

Perform a liver biopsy when diagnosis is unclear or to confi rm AIH or malignancy or other etiology