Fatal Herpes Simplex Virus Hepatitis in a Patient with Esophageal Cancer under Radiochemotherapy

Abstract

Background: Herpes simplex virus (HSV) infections are frequent. However, HSV hepatitis is rare and may lead to a life-threatening condition. Case Report: A 68-year-old patient with a locally advanced and inoperable esophageal carcinoma was treated with induction chemotherapy and combined chemoradiation. After a total of 9 weeks of treatment, he developed fulminant liver failure of unknown origin and died a few days later. Surprisingly, the post mortem examination revealed an HSV infection of the esophagus and an HSV-associated necrotisizing hepatitis. Conclusion: In this immunocompromised patient, we postulate an HSV-associated esophagitis that led to viremia and fulminant hepatitis. Especially in immunocompromised hosts, HSV hepatitis should be considered in the differential diagnosis in patients with anicteric hepatitis and marked elevation of transaminases. A liver biopsy is the quickest and most definitive diagnostic tool to diagnose HSV hepatitis. If this is not possible because of severe coagulopathy, polymerase chain reaction for HSV DNA should be performed. Awaiting diagnosis, a prompt empirical treatment with acyclovir has to be discussed in case of a characteristic biochemical profile.

Herpes Simplex Virus Load to Monitor Antiviral Treatment after Liver Transplantation for Acute Herpetic Hepatitis

“…Indeed 80 out of the 149 (54%) published cases occurred in immunocompromised patients, and 45 of them in solid organ transplant recipients. HSV-2 was responsible for 62% of cases [1][2][3][4][5][6][7][8]. Interestingly, the present patient had no apparent immunosuppression and, in the absence of specific IgM and IgG, we retained the diagnosis of primary infection, despite his advanced age.…”

“…Acute herpes simplex virus (HSV) hepatitis is a rare cause of acute liver failure (ALF), with only 148 reported cases [1][2][3][4][5][6][7][8]. Because of the poor prognosis it has been suggested to initiate specific antiviral therapy as soon as HSV hepatitis is suspected, while waiting for virological confirmation [9].…”

Fatal herpes simplex virus hepatitis following neoadjuvant chemoradiotherapy and anterior resection for rectal cancer

“…Grimm et al have previously reported a fulminant case of HSV hepatitis in a patient undergoing chemoradiotherapy for oesophageal cancer. 4 Our case differs in that there was a ten-week interval between treatment and infection in a seemingly well patient. Although myelosuppression is rare during treatment with capecitabine, the blood tests following radiotherapy showed a lymphopenia, suggesting a degree of immunological compromise, but this largely recovered before surgery.…”

Intense Therapy in Patients with Locally Advanced Esophageal Cancer beyond Hope for Surgical Cure: A Prospective, Multicenter Phase II Trial of the Swiss Group for Clinical Cancer Research (SAKK 76/02)

“…Peracute fatal herpes simplex hepatitis developed in 1 patient (unique patient number(UPN)17)4weeksafterthestartofCRT [18].Anotherpatient(UPN19)didnotstartCRTbecausethetumor volume was too large according to the radiooncologist and, therefore,retrospectivelythispatientwouldnothavemetthe trialinclusioncriteria.Radiotherapywasstoppedearly(after 39.6Gy)inathirdpatient(UPN15)becausetheradiooncologist was concerned about intolerable late sequalae resulting fromaverylargeirradiationvolume.…”