Willner and coworkers [1] reported on 256 patients with acute hepatitis A virus infection [1]. They observed 5 deaths caused by complications of fulminant hepatic failure. One of the decedents was a 23-year-old man who developed the acute respiratory distress syndrome and died of cardiac arrest.

We describe a 16-year-old girl with acute hepatitis A who developed fulminant hepatic failure, followed by the acute respiratory distress syndrome, and died of cardiac arrest. The patient was completely healthy until November 1997, when she was admitted to our hospital with fever, jaundice, and nausea. On admission, her body temperature was 39 °C and her skin and sclerae were icteric. On palpation, the patient reported tenderness in the right subchondral area. Abdominal ultrasonography yielded normal findings except for a liver length of 15 cm. Blood chemistry studies yielded the following: alanine aminotransferase level, 6756 U/L; aspartate aminotransferase level, 2145 U/L; alkaline phosphatase level, 215 U/L; -glutamyltransferase level, 331 U/L; total bilirubin level, 4.5 mg/dL; direct bilirubin level, 3.5 mg/dL; and prothrombin time, 22.9 seconds. The patient was strongly positive for anti-hepatitis A virus IgM antibody and negative for other serologic viral markers: hepatitis B virus, hepatitis C virus, HIV, Epstein-Barr virus, and cytomegalovirus. All other hematologic and biochemical variables were within normal limits.

During the days after admission, liver function became more impaired, coma due to fulminant hepatic failure was rapidly settled, and prothrombin time and activated partial thromboplastin time increased further. There was no evidence of bacterial sepsis, disseminated intravascular coagulation, or neurologic disease. On the fifth day, sudden respiratory failure occurred. The chest radiograph was consistent with the acute respiratory distress syndrome. Six hours after this diagnosis was made, the patient died of cardiac arrest despite cardiopulmonary resuscitation.

Even very young patients with acute hepatitis A virus infection can be at risk for a fatal outcome. Therefore, effective vaccination against hepatitis A is warranted, especially during epidemics and in developing countries.