In Reply.—

We thank Dr Hochman for his thoughtful comments on our recent case report. Dr Hochman asserts that patient 1 had neither a fulminant hepatitis nor hepatic failure causally related to infection with West Nile virus (WNV). He correctly points out, and we agree, that transaminases may become markedly elevated with hepatotropic viruses, perfusion injuries, or hepatotoxins. As Dr Hochman states, temporal elevations of liver enzymes can be seen in many infections. However, as we have described previously, patient 1 tested negative for several of the infectious agents that can lead to fulminant hepatic failure, including cytomegalovirus, adenovirus, hepatitis A, hepatitis B, hepatitis C, and Epstein-Barr virus. Dr Hochman's conclusion that the abnormal transaminases are secondary to ischemia is a possibility that we also considered. However, there was lack of evidence that patient 1 had ischemic injury to other vulnerable organ systems such as the kidney...

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