Herpes Simplex Virus (HSV) in the Differential for Fulminant Hepatic Failure

Abstract

Following an elective transphenoidal resection of a pituitary tumor, a 66-year-old Hispanic male acutely developed fulminant hepatic failure and severe coagulopathy. He received parenteral corticosteroids the day prior to surgery, and was first noted to have significant coagulopathy intraoperatively. Despite aggressive workup and treatment for fulminant hepatic failure, the patient developed multiorgan failure by post-operative day 2, and expired on post-operative day 3. On post-mortem examination, hemorrhagic necrosis of the liver was noted and microscopic examination revealed Cowdry type A inclusions, consistent with Herpes Simplex Virus (HSV) infection. This diagnosis was subsequently confirmed by immunehistochemistry. Fulminant hepatic failure due to HSV is a rare but highly fatal disease if untreated. Most case reports include only immunocompromised or pregnant patients. However, the lack of clinical suspicion in this previously healthy patient may have delayed prompt treatment with antiviral agents. It is important to raise the awareness of this rare and life-threatening, but potentially treatable, etiology when clinicians are faced with acute idiopathic fulminant hepatic failure.

Herpes Simplex Virus Hepatitis: A Presentation of Multi-Institutional Cases to Promote Early Diagnosis and Management of the Disease

“…While all of these were evident in cases 1 and 2, the patient in case 3 had a solitary rise in aminotransferases and mild ARF. Additionally, previous reports have noted an anicteric pattern of hepatitis as a commonality in presentation of this disease, though this was not seen in case 1 or 2 in this series [ 2 , 8 ]. This suggests that these findings and patterns together may support a diagnosis of HSV hepatitis but lack sensitivity and should not be used to rule out the diagnosis.…”

“…HSV hepatitis is an uncommon cause of acute liver failure, accounting for 0.8% of all cases and only 2% of all viral hepatitis [ 1 , 2 ]. It is mostly seen in immunocompromised individuals and pregnant women in their third trimester following an orogenital HSV-1 or HSV-2 infection, though previous reports have shown up to 25% of cases in immunocompetent individuals [ 1 ].…”

“…Other common features of HSV hepatitis in the absence of a biopsy are aminotransferases >500, fever, coagulopathy, encephalopathy, leukopenia, thrombocytopenia, and acute renal failure (ARF) [ 2 , 4 , 6 ] (see Table 1 for a summary of patient data and Table 2 for epidemiologic data from two large literature reviews on HSV hepatitis) [ 1 , 7 ]. While all of these were evident in cases 1 and 2, the patient in case 3 had a solitary rise in aminotransferases and mild ARF.…”

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

“…In general, providers should consider initiating empiric acyclovir in patients with acute or impending liver failure without known etiology, especially if the patient is immunosuppressed or has a known history of mucocutaneous lesions consistent with HSV. Superior survival has been demonstrated in patients with ALF stemming from viral hepatitis, although there is no differentiation made amongst the different viral etiologies [20]. e benefits of corticosteroid use in ALF remain a controversial topic and may further impact the immunocompromised status of the majority of the HSV hepatitis populace.…”

Fulminant Herpes Simplex Hepatitis Secondary to Adalimumab in Crohn’s Disease: A Case Report

“…2 It is most commonly associated with impaired cell-mediated immunity due to immunosuppressive medications, or conditions such as malnutrition, pregnancy, or malignancy. 3–7 There are a few reported cases of HSV hepatitis that developed in patients with inflammatory bowel disease (IBD) who were treated with steroids, with or without azathioprine. 3,5,7–14 The incidence of HSV hepatitis in IBD patients undergoing tumor necrosis factor (TNF)-α inhibitor therapy is, however, extremely rare.…”