*Purpose: On August 1, Philadelphia declared a public health emergency regarding rapid increases in new acute hepatitis A virus (HAV) cases, with 355 locally-acquired cases in 2019 through October (in 2018, by comparison, there were approximately 20 HAV cases in the city). Many cases have been linked to illicit drug use and homelessness, but 35% of cases had no known risk factors for its acquisition. Historically, <1% of patients with acute HAV develop acute liver failure (ALF), though in the midst of our current outbreak, four patients with ALF have required urgent orthotopic liver transplantation (OLT) at our academic transplant center. Given this rare presentation, we felt it timely to present our case series to the transplant community.

*Methods: Chart review and case description of 4 patients with acute HAV-ALF who were expeditiously evaluated, listed as status 1A and underwent OLT at our center, between August and October 2019.

*Results: The attached Table 1 summarizes the key demographic, clinical, laboratory and explant pathology data of the 4 cases. All 4 were transferred to our center from other hospitals with acute hepatocellular jaundice, were HAV IgM (+) and met AASLD criteria for ALF. 3 of 4 originated outside the city limits. All other causes of ALF were excluded. 3 of the 4 cases met King’s College Criteria for poor prognosis for non-acetaminophen-induced ALF, with an INR > 6.5. All 4 patients underwent successful OLT with uneventful post-operative courses and were discharged 6-12 days post-OLT. All 4 explants were remarkably similar histologically, showing acute hepatitis with massive (confluent) necrosis accompanied by a prominent lymphoplasmacytic inflammatory infiltrate and bile ductular proliferation. Other than 1 chronic HIV+ (non-viremic) patient, none had clearly identifiable risk factors for HAV acquisition. 1 of 4 patients used recreational marijuana, but no others were active drug users or experiencing homelessness.

*Conclusions: Although rare, patients presenting with acute HAV need close monitoring as they may rapidly progress to ALF. Early referral to a transplant center afforded timely access to OLT and yielded excellent short term survival, with long term survival benefit anticipated. Widespread HAV vaccination for high-risk individuals and close contacts of cases is the most important tool to curb this outbreak.

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