Can rhino/enterovirus (rhinovirus/enterovirus) infection cause elevated liver function, specifically abnormal liver function tests (LFTs) such as alanine transaminase (ALT) and aspartate transaminase (AST) indicating impaired liver function?

Rhinovirus/Enterovirus Infection and Liver Function Test Abnormalities

Rhinovirus/enterovirus infections can cause elevated liver function tests, though this is generally mild and transient, occurring as part of the systemic inflammatory response rather than direct viral hepatotoxicity.

Mechanism and Patterns of Liver Function Abnormalities

Rhinovirus and enterovirus belong to the Picornaviridae family, and while they primarily cause respiratory and gastrointestinal symptoms, they can affect liver function through:

• Systemic inflammatory responses that impact the liver
• Immune-cytopathic damage following inflammatory response
• Medication effects used to treat symptoms

The pattern of liver function test abnormalities typically includes:

• Mild to moderate elevations in AST and ALT (hepatocellular pattern)
• Less commonly, elevated bilirubin and gamma-glutamyl transferase (cholestatic pattern)
• Hypoalbuminemia in severe cases 1

Clinical Evidence and Severity

The severity of liver function abnormalities varies:

• In most cases, liver function abnormalities are mild and self-limiting
• More severe cases are reported with certain enterovirus serotypes, particularly in neonates
• Coxsackievirus B serotypes 3,4, and 5, as well as echovirus serotype 11, have been associated with acute liver failure in neonates 2
• In adults and older children, severe liver involvement is uncommon

Evaluation Approach

When elevated liver function tests are found in patients with rhinovirus/enterovirus infection:

1. Determine the pattern and severity of elevation (hepatocellular vs. cholestatic)
2. Consider timing of abnormalities (present at diagnosis vs. developing during illness)
3. Rule out pre-existing liver disease with appropriate serological tests:
   • Hepatitis B surface antigen
   • Anti-hepatitis C virus antibody 3
4. Review medications for potential hepatotoxicity:
   • Antipyretics (especially acetaminophen)
   • Antibiotics if prescribed for secondary bacterial infections
   • Anti-inflammatory medications 3

Management Recommendations

For patients with rhinovirus/enterovirus infection and elevated liver enzymes:

1. Regular monitoring of liver function tests during the course of illness
2. Supportive care focusing on hydration and symptom management
3. Avoid hepatotoxic medications when possible
4. Consider alternative antipyretics if acetaminophen is being used extensively 3, 1

Special Considerations

• Neonates: Enterovirus infections in neonates can cause acute liver failure with a fulminant course. Mortality rates can be up to 70% in cases of neonatal acute liver failure due to enteroviruses 2
• Immunocompromised patients: May experience more severe and prolonged liver function abnormalities
• Pre-existing liver disease: Patients with underlying liver conditions may experience exacerbation of their condition

Prognosis

In most immunocompetent children and adults:

• Hepatic dysfunction is generally transient
• Liver function tests typically normalize with resolution of the viral infection
• No specific antiviral therapy is required for the liver involvement 3, 1

Common Pitfalls

• Attributing elevated liver enzymes solely to medications without considering the viral infection itself
• Extensive hepatic workup for mild, transient elevations that are expected to resolve
• Failure to consider enterovirus in cases of acute liver failure in neonates
• Overlooking the possibility of co-infections with other hepatotropic viruses

In summary, while rhinovirus/enterovirus can cause elevated liver function tests, this is typically mild and self-limiting in most patients, with the exception of certain enterovirus infections in neonates that can lead to severe acute liver failure.