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

Abstract

We describe the case of a young patient who contracted fatal herpes simplex virus hepatitis following neoadjuvant chemoradiotherapy and anterior resection for rectal cancer. The rarity and non-specific presentation of this treatable disease, which masqueraded as the sequelae of postoperative sepsis, resulted in a diagnosis following death. Features that should prompt inclusion of herpes simplex virus hepatitis in the differential diagnoses are suggested and the case is a reminder of how neoadjuvant therapy may subtly alter a patient's immunocompetency.

Management of herpesvirus reactivations in patients with solid tumours and hematologic malignancies: update of the Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO) on herpes simplex virus type 1, herpes simplex virus type 2, and varicella zoster virus

“…Symptomatic reactivation typically occurs as herpes labialis ("coldsores"), but in the immunocompromised person, herpes stomatitis is often seen [12] (Table 2). Life-threatening reactivations are HSV encephalitis, HSV pneumonitis, and rarely other visceral manifestations [5,[16][17][18] (Table 2). Besides, HSV-1 is increasingly found in genital herpes [19] (Table 2).…”

“…Compared to patients with hematologic malignancies with cumulative incidences of herpesvirus reactivations of up to 20% during the treatment phase and 5-year follow up, frequencies of herpesvirus reactivations are low (< 10%) in patients with solid tumours [4]. However, case reports and case series about severe complications by HSV or VZV have been described [5,[16][17][18]. This holds also true for patients treated with immune checkpoint inhibitors with or without chemotherapy [71,72].…”

Liver and Bile Duct Infections

“…Liver involvement occurs primarily in neonates, pregnant patients, and immunocompromised patients, although immunocompetent adults are rarely affected as well. 115,116 Dissemination usually occurs in primary infection (particularly if the patient is immunocompetent) but has also been described in reactivation. 117 In children, severe protein-calorie malnutrition and the postmeasles Serology is of little use, especially in the immunocompromised patient.…”

“…117 Intranuclear inclusions of two types can be found in hepatocytes at the edge of the necrotic foci, and virally infected cells are often multinucleated. 115,116 Cowdry type A inclusions are large, eosinophilic intranuclear inclusions surrounded by a halo, whereas type B inclusions replace the entire nucleus with a basophilic groundglass appearance. Immunohistochemistry for herpes type I and type II antigens highlights the nuclear inclusions, and overlap between the two antibodies is frequent.…”

“…Immunohistochemistry for herpes type I and type II antigens highlights the nuclear inclusions, and overlap between the two antibodies is frequent. 115,116 Treatment with antiviral drugs before the biopsy is obtained may result in a biopsy specimen with extensive necrosis but without diagnostic inclusions. 116 The main differential is varicella zoster virus (VZV) infection and adenovirus infection, both of which have a similar histologic appearance; immunohistochemical staining or PCR may be necessary to distinguish these infections.…”