Fulminant Hepatitis During Herpes Simplex Virus Infection in Apparently Immunocompetent Adults: Report of Two Cases and Review of the Literature

Abstract

Two apparently immunocompetent adult patients developed acute fulminant hepatitis during presumptive primary herpes simplex virus type 1 (HSV-1) infection without any visible mucocutaneous lesions. HSV hepatitis was not suspected in the case of patient 1, who died without treatment. Patient 2 was empirically treated with acyclovir because of the triad of high fever, leukopenia, and markedly elevated levels of aminotransferases, and this patient survived. Most immunocompetent patients with fulminant HSV hepatitis do not have visible mucocutaneous ulcers, and HSV is frequently not considered as a cause of acute hepatitis. In summary, fulminant hepatitis can occur during HSV infections, the diagnosis is frequently missed or delayed because of the absence of mucocutaneous ulcerations, and patients who receive early empirical treatment with acyclovir can survive this illness.

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

“…Most of the case studies have demonstrated marked elevations of transaminases with AST > ALT (up to 1000-fold). Leukopenia is also a common finding in HSV hepatitis [3][4][5][6][7]. In our case, the leukopenia and the thrombopenia are likely due to myelosuppression caused by the chemotherapy with docetaxel and cisplatin.…”

“…Therefore, HSV hepatitis should be suspected in immunocompromised hosts with anicteric hepatitis and marked elevation of transaminases, fever and leukopenia. Mucocutaneous lesions are not necessarily part of the diagnosis, as over 40% of patients will not have identifiable oral or genital lesions or a prior history of HSV infection [3,6,7]. Physicians need to be aware of the clinical abnormalities.…”

“…If there are no obvious risk factors for other forms of hepatitis, we suggest to perform a liver biopsy or PCR for HSV in the peripheral blood prior to an empirical therapy with acyclovir. Only a rapid start of a specific therapy can improve the serious prognosis of this illness [3,5,7,12,14].…”

Acute liver failure in the setting of herpes simplex virus and coexistent acute fatty liver of pregnancy

“…Although HSV infection may present with mild nonspecific viral symptoms, most HSV infections are asymptomatic. Only 30%-50% show characteristic herpetic skin lesions [2][3][4] . Fulminant HSV hepatitis is a rare presentation of HSV infection and accounts for only 1% of all acute liver failure cases and 2% of all viral causes of acute liver failure 4.…”

Acute Hepatitis Due to Epstein–Barr Virus in an Immunocompetent Patient

“…A diagnosis of HSV-induced hepatitis is difficult because clinical suspicion is often low, especially in immunocompetent patients. In addition, mucocutaneous lesions have been seen in only 44% of immunocompetent patients; therefore, their absence cannot rule out disease [11]. However, early diagnosis is essential because the course of HSV-induced hepatitis is rapid and fatal.…”