HSV1 viremia with fulminant hepatitis as opportunistic sequela in severe COVID-19

Introduction: Acute liver failure (ALF) is a life-threatening condition that remains challenging for physicians despite several advances in supportive care. Etiologies vary worldwide, with herpes simplex virus (HSV) hepatitis representing less than 1% of cases. Despite its low incidence, ALF is a lethal cause of acute necrotizing hepatitis and has a high mortality. Early antiviral treatment is beneficial for survival and decreased liver transplantation necessity. However, plasmapheresis, despite its theoretical potential benefit, is scarcely reported. Patient concerns: A 25-year-old woman with no known disease presented with painful pharynx ulcers, increased transaminases and impaired liver function. Diagnosis: ALF due to a disseminated HSV-2 primary infection was diagnosed with a positive polymerase chain reaction for HSV-2 in the biopsied liver tissue and blood. Interventions: Empiric antiviral treatment was initiated. After clinical deterioration, plasmapheresis was also initiated. Outcomes: After 6 cycles of plasmapheresis and supportive care, the patient's condition improved without undergoing liver transplantation. Conclusions: ALF is a life-threatening condition, and HSV as an etiology must be suspected based on background, clinical manifestation, and laboratory information. The potential role of plasmapheresis in HSV hepatitis should be considered.

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“…[ 13 ] Recently, it was described as a complication in patients with severe COVID-19 treated with immunosuppressive therapy. [ 14 ]…”

Section: Discussionmentioning

confidence: 99%

“…[13] Recently, it was described as a complication in patients with severe COVID-19 treated with immunosuppressive therapy. [14] Early treatment with acyclovir can inhibit viral replication and improve outcomes. [15] Unfortunately, the diagnosis of HSV is usually late.…”

Section: Discussionmentioning

confidence: 99%

Acute liver failure due to herpes simplex virus: diagnostic clues and potential role of plasmapheresis

et al. 2021

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“…HSV-1 reactivation in the presence of severe manifestations such as systemic skin manifestations, hepatitis, or encephalitis (all of them have been reported to possibly occur [ 14 , 44 , 60 , 61 ]), as well as in presence of worsening of respiratory function and pulmonary lesions [ 15 , 58 ], may be considered as clinically significant. However, reactivations without a manifest clinical picture are more controversial.…”

Section: Methodsmentioning

confidence: 99%

Herpes Simplex Virus 1 (HSV-1) Reactivation in Critically Ill COVID-19 Patients: A Brief Narrative Review

et al. 2022

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Systemic or pulmonary reactivations of herpes simplex virus 1 (HSV-1) have been reported in critically ill patients with COVID-19, posing a dilemma for clinicians in terms of their diagnostic and clinical relevance. Prevalence of HSV-1 reactivation may be as high as [ 40% in this population, but with large heterogeneity across studies, likely reflecting the different samples and/or cut-offs for defining reactivation. There is frequently agreement on the clinical significance of HSV-1 reactivation in the presence of severe manifestations clearly attributable to the virus. However, the clinical implications of HSV-1 reactivations in the absence of manifest signs and symptoms remain controversial. Our review aims at providing immunological background and at reviewing clinical findings on HSV-1 reactivations in critically ill patients with COVID-19.

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“…Other than cohort studies, there have also been case reports regarding COVID-19 induced ALI in ICU patients. Of note, a case report from Italy highlighted a rare case of ALI progressing to acute liver failure and eventually death[ 38 ]. It involved 2 critically ill COVID-19 patients hospitalized in the ICU due to severe ARDS.…”

Section: Existing Evidencementioning

confidence: 99%

“…The patients were treated with tocilizumab, as part of the anti-cytokine storm regimen, which however seemed to have aggravated the underlying COVID-19 immunosuppression, thus facilitating the development of opportunistic infections in the already immunocompromised patients. Indeed, a few days prior to their death, lab tests revealed Herpes simplex virus 1 viremia leading to fulminant hepatitis with dramatic increases in ALT, AST, bilirubin and INR levels and resulting in fatal outcomes for both patients[ 38 ].…”

Section: Existing Evidencementioning

confidence: 99%

Acute liver injury in COVID-19 patients hospitalized in the intensive care unit: Narrative review

Polyzogopoulou¹,

Amoiridou²,

Abraham³

et al. 2022

World J Gastroenterol

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In recent years, humanity has been confronted with a global pandemic due to coronavirus disease 2019 (COVID-19), which has caused an unprecedented health and economic crisis worldwide. Apart from the respiratory symptoms, which are considered the principal manifestations of COVID-19, it has been recognized that COVID-19 constitutes a systemic inflammatory process affecting multiple organ systems. Across the spectrum of organ involvement in COVID-19, acute liver injury (ALI) has been gradually gaining increasing attention by the international scientific community. COVID-19 associated liver impairment can affect a considerable proportion of COVID-19 patients and seems to correlate with the severity of the disease course. Indeed, COVID-19 patients hospitalized in the intensive care unit (ICU) run a greater risk of developing ALI due to the severity of their clinical condition and in the context of multi-organ failure. The putative pathophysiological mechanisms of COVID-19 induced ALI in ICU patients remain poorly understood and appear to be multifactorial in nature. Several theories have been proposed to explain the occurrence of ALI in the ICU setting, such as hypoperfusion and ischemia due to hemodynamic instability, passive liver congestion as a result of congestive heart failure, ischemia-reperfusion injury, hypoxia due to respiratory failure, mechanical ventilation itself, sepsis and septic shock, cytokine storm, endotheliitis with concomitant coagulopathy, drug-induced liver injury, parenteral nutrition and direct cytopathic viral effect. It should be noted that no specific therapy for COVID-19 induced ALI exists. Therefore, the therapeutic approach lies in preventive measures and is exclusively supportive once ALI ensues. The aim of the current review is to scrutinize the existing evidence on COVID-19 associated ALI in ICU patients, explore its clinical implications, shed light on the underlying pathophysiological mechanisms and propose potential therapeutic approaches. Ongoing research on the particular scientific field will further elucidate the pathophysiology behind ALI and address unresolved issues, in the hope of mitigating the tremendous health consequences imposed by COVID-19 on ICU patients.

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HSV1 viremia with fulminant hepatitis as opportunistic sequela in severe COVID-19

Cited by 8 publications

References 9 publications

Acute liver failure due to herpes simplex virus: diagnostic clues and potential role of plasmapheresis

Acute liver failure due to herpes simplex virus: diagnostic clues and potential role of plasmapheresis

Herpes Simplex Virus 1 (HSV-1) Reactivation in Critically Ill COVID-19 Patients: A Brief Narrative Review

Acute liver injury in COVID-19 patients hospitalized in the intensive care unit: Narrative review

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