King's College criteria and the Clichy-Villejuif criteria require adjustments for assessing acute liver failure due to yellow fever

Table 1 Liver transplant indication criteria: King's College and Clinic-Villejuif

King's College criteria		Clichy-Villejuif criteria
Paracetamol induced liver failure (Acetaminophen)	Non-paracetamol induced liver failure
Arterial potential of hydrogen < 7.3 (irrespective of the grade of encephalopathy)	PT > 100 seconds (INR > 6.5)	Age: Patients over the age of 30 years are at higher risk and are more likely to need a transplant
All three of the following	Any three of the following	Factor V levels
PT > 100 seconds (INR > 6.5)	Age < 10 years or > 40 years	Factor V level < 20% of normal for patients over 30 years old
Serum creatinine > 3.4 mg/dL (300 μmol/L)	Etiology: Non-A hepatitis, non-B hepatitis, and idiosyncratic drug reactions	Factor V level < 30% of normal for patients under 30 years old
Grade III or IV encephalopathy	Duration of jaundice before encephalopathy > 7 days. Prothrombin time > 50 seconds (INR > 3.5). Serum bilirubin > 17.5 mg/dL (300 μmol/L)
		Grade of encephalopathy
		Presence of grade III or IV encephalopathy indicates a severe case

INR: International normalized ratio; PT: Prothrombin time.

Table 2 Demographic characteristics of patients with acute liver disease due to yellow fever at Felicio Rocho Hospital between January 20 and February 20, 2018 (n = 14), n (%)

Characteristics	Patients
Age (years); median (minimum-maximum)	53 (23-69)
Male sex	13 (92.8)
Vaccination for yellow fever more than 10 days ago	3 (21.4)
Comorbidities
Smoking	3 (21.4)
Hypertension	2 (21.4)
Immunosuppressed (previous renal transplant)	1 (7.1)
Diabetes	0
Time from symptoms onset to admission (days), mean (minimum-maximum)	4-7 (1-8)
Signs and symptoms at hospital admission
Myalgia	12 (85.7)
Fever	11 (78.6)
Jaundice	11 (78.6)
Vomiting	7 (50)
Headache	6 (42.9)
Abdominal pain	4 (28.6)
Diarrhea	2 (14.3)
Distance between exposure location and hospital (km), mean (minimum-maximum)	1487 (30-291)
Rural workers	6 (42.6)

Table 3 Clinical data of patients hospitalized at Felicio Rocho Hospital in 2018 yellow fever outbreak

Patients	Age (years)	Gender	Platelets (mL)	Aspartate aminotransferase (IU/L)	Alanine aminotransferase (IU/L)	Bilirubin (mg/dL)	International normalized ratio	Creatinine (mg/dL)	Lactate (IU/L)	Encephalopathy	Transplantation	Outcome
1	53	M	29000	9693	2282	17.2	2.9	12.4	133	4	No	Dead
2	64	M	26000	7900	4648	3.54	2.3	6.48	61	2	Yes	Alive
3	37	M	58000	8151	7206	8.16	> 10	7.1	164	3	Yes	Dead
4	49	M	89000	5160	2463	5.12	1.81	8.74	40	No	No	Alive
5	39	M	58000	8707	4509	6.81	2.9	8.81	125	4	No	Dead
6	58	M	12000	12590	7446	21.9	1.65	1.17	42	No	No	Alive
7	69	M	35000	8572	3987	5.9	> 10	8.11	135	3	Yes	Dead
8	57	M	29000	8451	3854	10.1	4.4	7.49	184	4	No	Dead
9	57	F	46000	28266	9680	4.47	> 10	5.06	115	4	No	Dead
10	63	M	56000	3650	2215	5.41	1.12	0.77	20	No	No	Alive
11	23	M	14000	9471	3926	13.47	1.7	0.92	20	No	No	Alive
12	46	M	79000	2791	2126	01.02	1.1	1.2	8	No	No	Alive
13	47	M	38000	12207	2992	8.15	2.9	1.46	41	3	Yes	Alive
14	40	M	49000	157	288	0.49	1.1	0.82	15	No	No	Alive

M: Male; F: Female.

Table 4 Correlations between international normalized ratio, factor V, onset day of neurological symptoms, neurological symptoms, and outcomes in patients with acute liver disease due to yellow fever at Felicio Rocho Hospital between January 20 and February 20, 2018 (n = 14)

Cases	Concentrated fresh plasma	D4	D5	D6	D7	D8	D9	D10	D12	D14	D4	D5	D6	D7	D8	D9	D10	D12	D14	Day of onset of neurological symptoms	Neurological symptoms	Outcome
		International normalized ratio									Factor V (%)
Case 1	Yes	-	-	-	-	1.7	-	1.2	-	2.9	-	-	-	-	-	-	-	-	-	D10	Initial slowing with rapid progression to stupor and coma	Death
Case 9	Yes	> 7	5.5	-	-	-	-	-	-	-	-	8.8	-	-	-	-	-	-	-	D5	Drowsiness and flapping with rapid progression to coma	Death
Case 12	Yes	-	-	4.4	2.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	D5	Drowsiness, disorientation, progression to stupor and coma	Death
Case 13	Yes	2	2.2	3	2.7	-	-	-	-	-	16.6	22.4	-	-	-	-	-	-	-	D5	Recurrent seizures	Death
Case 4	Yes	4.1	6.6	7.9	> 9	-	-	-	-	-	-	-	15.6	-	-	-	-	-	-	D6	Agitation was intubated due to respiratory failure	Transplant
Case 8	No	-	2.3	2	-	-	-	-	-	-	15.8	21.5	-	-	-	-	-	-	-	D5	Slowing and mild disorientation	Transplant
Case 11	Yes	-	> 9	> 10	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	D4	Drowsiness and flapping with rapid progression to coma	Transplant
Case 14	Yes	-	2.6	2.7	2	2.4	2.9	2.1	-	-	-	-	21	21.7	21.5	12.8	-	-	-	D9	Slowing, flapping, progression to stupor and coma	Transplant
Case 2	No	1.1	1.1	1	1	1	-	-	-	-	-	-	-	-	161	-	-	-	-	-		Clinical improvement
Case 3	No	1	1	1	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		Clinical improvement
Case 5	No	1.6	1.8	1.7	1.6	1.4	1.3	1.3	-	1.2	-	-	-	-	-	-	-	158	-	D10		Clinical improvement
Case 6	No	-	-	1.7	1.7	1.5	-	-	-	1.1	81.6	-	-	-	-	-	-	-	-	-		Clinical improvement
Case 7	No	1.4	1.5	1.6	1.7	1.6	1.4	1.4	-	1.2	44.4	-	-	-	-	-	-	-	-	D9	Mental confusion and disorientation, complete recovery. Bacterial sepsis	Clinical improvement
Case 10	No	1.2	1.1	1	1	1	1.1	1.1	-	-	-	-	-	-	-	-	-	-	-	-		Clinical improvement

D4: Day 4; D5: Day 5; D6: Day 6; D7: Day 7; D8: Day 8; D9: Day 9; D10: Day 10; D12: Day 12; D14: Day 14.