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

Abstract

Objective To compare three cases of Herpes simplex virus (HSV) hepatitis to increase early diagnosis of the disease. Case 1. A 23-year-old man with Crohn's disease and oral HSV. HSV hepatitis was diagnosed clinically and he improved with acyclovir. Case 2. An 18-year-old G1P0 woman with transaminitis. Despite early empiric acyclovir therapy, she died due to fulminant liver failure. Case 3. A 65-year-old woman who developed transaminitis after liver transplant. Diagnosis was confirmed by biopsy and she had resolution of acute liver failure with acyclovir. Conclusion It is imperative that clinicians be aware of patients at high risk for developing HSV hepatitis to increase timely diagnosis and prevent morbidity and fatality.

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]. Juhl and colleagues suggest that although HSV viremia is possible, it seems to be limited to primary infections [5].…”

“…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].…”

“…Computerized tomography and magnetic resonance imaging of the abdomen in viral hepatitis is nonspecific and includes hepatomegaly and periportal edema [14]. e gold standard diagnostic modality is histopathologic confirmation from liver biopsy which shows hemorrhagic necrosis, inflammation, enlarged ground glass nuclei with marginalized chromatin, and HSV immunostaining [3]. If liver biopsy is not available or cannot be done timely, clinical markers such as aminotransferases >500 U/L, fever, coagulopathy, encephalopathy, leukopenia, thrombocytopenia, and acute renal failure coupled with a positive HSV PCR should prompt the initiation of antiviral treatment [3].…”

Unusual oral presentation of HSV-1 lesions in an adult liver transplant recipient

“…The true prevalence of atypical HSV dermatological presentations in liver transplant patients is unknown. It is likely that such atypical presentations have led to under-recognition, and as such, under-reporting in the literature, as well as delays in the treatment and prevention of HSV complications 11…”

Herpes hepatitis as a complication of total abdominal hysterectomy; an unusual complication of abdominal instrumentation

“…Herpes simplex virus commonly causes mucocutaneous infections in the general population. Hepatitis, as a complication of HSV, is rare phenomenon that represents <2% of viral hepatitides and is most prevalent in the immunocompromised or pregnant women following oro‐genital infection . This can rapidly progress to fulminant disease with declining liver function and cytopenias and can be fatal if left undiagnosed or untreated .…”