Fulminant hepatic failure secondary to acyclovir-resistant herpes simplex virus

Abstract

Liver failure is a frequent and serious complication that causes morbidity and mortality in haematopoietic stem cell transplantation (HCT) recipients. Liver dysfunction in these patients can be related to infectious causes, most common viral hepatitis. We report a case of disseminated acyclovir-resistant herpes simplex virus (HSV) infection following HCT that led to acute liver failure and death. Although rare, HSV hepatitis leads to high morbidity and mortality and should be considered in the differential diagnosis of HCT recipients with marked elevation of hepatic transaminase. Acyclovir is a first-line therapy for HSV infection; however, acyclovir-resistant viral strains should be considered and alternative HSV therapies given in HCT recipients whose HSV infection does not improve on acyclovir therapy.

Hematopoietic stem cell transplantation and the noncytomegalovirus herpesviruses

“…19,20 HSV can cause fulminant hepatitis which typically presents with fever, right upper quadrant pain, and elevated transaminases in the absence of skin lesions. 8,21 Some patients with HSV hepatitis can present with other liver diseases related to HSCT such as hepatic veno-occlusive disease and hepatic GVHD. 8 The gold standard for diagnosis is liver biopsy, although usually limited by the coagulopathy commonly seen in this patient population.…”

Herpes Simplex Virus Hepatitis: A Brief Review of an Oft-overlooked Pathology

“…In cases of acyclovir resistant HSV hepatitis, Foscarnet or Cidofovir may be employed. These two agents inhibit the catalytic unit of viral DNA polymerase and do not require activation by thymidine kinase [21]. Chaudhary et al reported one case of HSV hepatitis that showed no improvement with acyclovir, but when foscarnet was added the patient’s mental status improved and she was ultimately discharged home with no need for liver transplantation [22].…”

Acute Liver Failure

“…Hepatitis A and E viruses are the most common cause of acute liver failure with a mortality up to 50% in developing countries, whereas hepatitis B is the leading cause in Asian and Mediterranean countries (Bernal & Wendon, 2013). In addition to the hepatitis virus, herpes simplex, herpes zoster, varicella zoster, CMV, Epstein Barr virus, and parvovirus can also cause acute liver failure (Shahani, 2016;Thayapararajah, Gulka, Al-Amri, Das, & Young, 2013).…”

“…The most common causes are Staphylococcus, Streptococcus, and enteric gram-bacilli, and fungal infections, particularly candida. Antibiotics given are empirical antibiotics, broad spectrum for positive and negative gram, the third generation of cephalosporins, and while awaiting the results of culture, vancomycin (Schilsky et al, 2009;Shahani, 2016). If the condition does not improve, then antifungal administration should be considered.…”

“…Symptoms include jaundice, coagulopathy, and damage to many organs (Khashab, Tector, & Kwo, 2007). The number of ALF cases is about 10 to 1 million people each year (Bernal & Wendon, 2013) 2,000-2,800 cases of which are found in the United States and about 15% cases are undetectable (Shahani, 2016).…”