Herpes Simplex Virus Hepatitis in an Immunocompetent Adult: A Fatal Outcome due to Liver Failure

Abstract

Objective. To present a case of a healthy 41-year-old female who developed fulminant hepatic failure leading to death. The cause of hepatic failure identified on postmortem exam was herpes simplex virus hepatitis. Design. Observation of a single patient. Setting. Intensive care unit of a tertiary care university teaching hospital in Canada. Patient. 41-year-old previously healthy female presenting with a nonspecific viral illness and systemic inflammatory response syndrome. Intervention. The patient was treated with intravenous fluids and broad-spectrum antibiotics. On the second day of admission, she was found to have elevated transaminases, and, over 48 hours, she progressed to fulminant liver failure with disseminated intravascular coagulopathy, refractory lactic acidosis, and shock. She progressed to respiratory failure requiring intubation and mechanical ventilation. She was started on N-acetylcysteine, a bicarbonate infusion, hemodialysis, and multiple vasopressors and inotropes. Measurements and Main Results. Despite treatment, the patient died roughly 70 hours after her initial presentation to hospital. Her postmortem liver biopsy revealed herpes simplex virus hepatitis as her cause of death. Conclusions. Herpes simplex virus must be considered in all patients presenting with liver failure of unknown cause. If suspected, prompt treatment with acyclovir should be initiated.

Herpes Simplex Virus-2 Hepatitis: A Case Report and Review of the Literature

“…Hepatitis secondary to infection with HSV serotype 1 or 2 is a rare diagnosis that has a propensity to rapidly progress to fulminant liver failure [3], with mortality rates that approach 90% [4]. HSV hepatitis most commonly affects patients with impaired immunity and pregnant women in their third trimester, though literature reports have reported up to 25% of cases in immunocompetent individuals [3].…”

“…Patients often present with nonspecific flu-like symptoms including fever, myalgias, and abdominal pain [6,7]. e characteristic mucocutaneous herpetic skin lesions are found only in 30-50% of cases [4]. Common laboratory findings included leukopenia, thrombocytopenia, and coagulopathy.…”

“…Renal failure and disseminated intravascular coagulopathy are reported less often, and encephalopathy, if seen, is often a late manifestation [3]. Approximately 90% of patients with HSV hepatitis have a characteristic liver profile known as "anicteric hepatitis," which refers to a 100-1000fold increase in transaminases, AST greater than ALT, with a relatively normal or low bilirubin [4,[8][9][10][11][12].…”

Herpes simplex virus 2 hepatitis in a lung transplant recipient: a diagnostic challenge

“…Norvell et al's literature review showed that a clinical suspicion of HSV hepatitis was raised in only 22.6% of 137 cases. Laboratory investigations often demonstrate leukopenia, thrombocytopenia, coagulopathy, a relatively low bilirubin level, and a significant increase in liver enzymes (100‐ to 1000‐fold), with AST greater than ALT . In our case, the diagnosis was mistaken for an acute cholecystitis, because of the confirmed calculous gallbladder and major gallbladder wall edema, which are common findings in cystic fibrosis patients.…”

Immune- and Nonimmune-Compartment-Specific Interferon Responses Are Critical Determinants of Herpes Simplex Virus-Induced Generalized Infections and Acute Liver Failure

“…That said, IFN responsiveness of the circulating immune cells clearly contributes to controlling generalized infections, particularly in the liver. The incidence of HSV-induced liver failure is well established in the case report literature, with most cases occurring in immunocompromised patients, although some immunocompetent patients succumb to the disease (21,42,43). Although this disease has gained attention, especially in the transplant literature, to our knowledge there has been no basic research on HSV hepatotropism and the role of innate immunity therein.…”