Genital herpes and hepatitis in healthy young adults

Viral Diseases of the Liver

Viruses other than the classic hepatotropic viruses, hepatitis A through E, may cause hepatic injury [1]. Among these are Epstein–Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV), varicella zoster virus (VZV), human herpes viruses (HHV) 6, 7, and 8, human parvovirus B19, and adenoviruses (Table 11.1). The clinical presentation of infections with these viruses may be indistinguishable from that associated with infection with classic hepatotropic viruses. The presentation ranges from mild and transient elevation of aminotransferases to acute hepatitis and can also lead to acute liver failure [1]. These viruses should be considered as possible etiologic agents in patients who have acute liver injury and whose serologic markers for the classic hepatotropic viruses are not indicative of an active infection [1]. In the present chapter, we review the clinical manifestations and the potential for immune-mediated liver injury associated with several of these viruses (see summary Table 11.2).

Synergistic control of herpes simplex virus pathogenesis by IRF-3, and IRF-7 revealed through non-invasive bioluminescence imaging

Interferon regulatory factors IRF-3 and IRF-7 are central to the establishment of the innate antiviral response. This study examines HSV-1 pathogenesis in IRF-3(-/-), IRF-7(-/-) and double-deleted IRF3/7(-/-) (DKO) mice. Bioluminescence imaging of infection revealed that DKO mice developed visceral infection following corneal inoculation, along with increased viral burdens in all tissues relative to single knockout mice. While all DKO mice synchronously reached endpoint criteria 5 days post infection, the IRF-7(-/-) mice survived longer, indicating that although IRF-7 is dominant, IRF-3 also plays a role in controlling disease. Higher levels of systemic pro-inflammatory cytokines were found in IRF7(-/-) and DKO mice relative to wild-type and IRF-3(-/-) mice, and IL-6 and G-CSF, indicative of sepsis, were increased in the DKO mice relative to wild-type or single-knockout mice. In addition to controlling viral replication, IRF-3 and -7 therefore play coordinating roles in modulation of inflammation during HSV infection.

Hépatite aiguë lors d’une primo-infection à Herpès simplex virus 2 chez un malade atteint d’un lupus érythémateux disséminé

BACKGROUND

Herpes simplex virus hepatitis is a rare complication associated with a poor prognosis and a high mortality rate. It mainly affects adults with impaired cell-mediated immunity. Mucocutaneous involvement is seen in only 57% to 70% of patients and the clinical aspects of the lesions may sometimes be misleading. Here we report a new case that developed during primary HSV-2 infection in a patient with systemic lupus erythematosus.

CASE REPORT

A 57 year-old man with systemic lupus erythematosus treated with oral prednisone presented a disseminated varicella-like eruption with acute liver failure related to primary genital HSV-2 infection. Type-specific HSV deoxyribonucleic acid amplification by polymerase chain reaction on serum and oral lesion samples revealed type 2 HSV. Dramatic improvement was observed with parenteral acyclovir.

DISCUSSION

Hepatitis due to HSV is a rare but potentially fatal disorder chiefly affecting adults with impaired immune systems. In this case, HSV affects the liver during primary or recurrent infection. If initiated quickly, parenteral acyclovir can cure hepatitis, which means that this diagnosis must be considered in both immunocompromised and immunocompetent patients with high fever, leucopoenia and marked elevation of aminotransferase levels. Mucocutaneous signs are present in only 57 to 70% of cases. Careful physical examination to detect herpes lesions should be done in all cases of acute liver failure. HSV viremia testing may confirm the diagnosis by non-invasive means. Patients with systemic lupus erythematosus are at increased risk for infection due to immunosuppressive drugs, but also to numerous intrinsic immunologic abnormalities such as a recently reported deficit in NK cells and plasmacytoid dendritic cells.

Infection and direct injury in human hepatocyte explants and a hepatoblastoma cell line due to hepatiticomimetic (non-hepatitis) viruses

Hepatitis is caused by hepatitis viruses, but hepatitis or hepatocellular enzyme abnormalities is sometimes associated with infection by the hepatiticomimetic viruses. The direct and indirect effects of infection with hepatiticomimetic viruses were examined in two human hepatocyte systems. Poliovirus, adenovirus, and herpes simplex virus (HSV) induced cytopathology in Hep G2 cells. Measles virus caused no change in hepatocytes. Poliovirus infection did not affect cellular protein synthesis, and the peak of hepatocellular enzyme release coincided with the peak of virus release. The increase in adenovirus protein synthesis correlated with the decrease of transferrin synthesis, and enzyme release was not prominent. HSV induced viral protein synthesis with enhanced processing and inhibition of synthesis of alpha1-antitrypsin. The peak of enzyme release was later than the peak of virus release. In primary hepatocytes, poliovirus, adenovirus, and induced extensive cytopathology and enzyme release, and VZV caused cytopathology and significant but minute enzyme release. The ratio of lactate dehydrogenase to aspartate aminotransferase release was larger in poliovirus infection in both hepatocytes than in HSV or VZV infection. Although poliovirus and adenovirus are released by cytolysis and HSV and VZV are secreted by exocytosis of cytoplasmic vacuoles, enzyme release was independent of the type of virus release. Adenovirus showed strong cytotoxicity but did not modify the membrane nor cause enzyme release. Enzyme release was associated with modification of the surface membrane due to apoptosis with poliovirus and necrosis with HSV. Consequently hepatocellular injury by viral infection did not reflect the amount or pattern of hepatocellular enzyme release.

Herpes simplex virus hepatitis: expanding the spectrum of disease

We describe 2 transplant patients with herpes simplex virus (HSV) hepatitis who were minimally symptomatic throughout their illness. The spectrum of disease caused by HSV hepatitis is more variable than previously reported in this population. HSV hepatitis should be considered in immunocompromised hosts with elevated transaminases without evidence of fulminant hepatic necrosis.

Hepatitis por virus del grupo herpes

In immunocompetent patients, primary infection by herpes simplex virus (HSV), varicella-zoster virus (VZV), cytomegalovirus (CMV), human herpesvirus 6, and Epstein-Barr virus (EBV) generally produces mild, self-limited hepatitis. Primary infection by HSV in neonates and pregnant women, and infection by VZV in hematological and bone marrow recipients can cause fulminant hepatitis without characteristic skin lesions. In liver transplant recipients, hepatitis is the most common expression of CMV infection and the related symptoms are indistinguishable from those of acute rejection. Persistent hepatitis is a manifestation of the syndrome of active chronic infection by the EBV. Fulminating hepatitis due to herpes virus can be treated effectively if therapy is started early; hence, a high degree of clinical suspicion and inclusion of herpes virus in the differential diagnosis of this syndrome is necessary.

Herpesvirus infection of the liver

The human herpesviruses can produce a wide variety of disease in the liver (Table 7). The immunocompromised host is particularly susceptible to hepatic manifestations of herpesvirus disease. CMV is the most common opportunistic pathogen in the immunocompromised patient. The clinical presentation of hepatic herpesvirus infection is often nonspecific. A high index of suspicion and rapid progression to liver biopsy to document viral replication (alpha- and betaherpesviruses) or outgrowth of virus-infected cells (gammaherpesviruses) can lead to lifesaving therapeutic interventions.

Fulminant herpes hepatitis in a healthy adult: a treatable disorder?

Hepatitis due to herpes simplex virus (HSV) is a potentially fatal disorder that is often not considered in the differential diagnosis of acute hepatitis. This disease occurs most often in patients with impaired immunity and is very uncommon in healthy patients. HSV hepatitis presents with a wide clinical spectrum, and the clinical diagnosis is difficult. We describe a case of disseminated herpes virus infection with fulminant hepatitis mimicking an acute human immunodeficiency virus infection in a 33-year-old healthy man. Preliminary studies suggest that early treatment of HSV hepatitis with acyclovir may be beneficial in these patients. A high index of suspicion and the availability of early diagnostic tools, such as HSV DNA detection, may dramatically improve the clinical outcome of severe HSV hepatitis.

Disseminated herpes simplex virus infection in an apparently immunocompetent woman

A young, previously healthy woman developed bilateral exudative tonsillitis that was associated with severe systemic symptoms. This was followed by evidence of multisystem disease with acute abdominal pain, raised liver enzyme levels, respiratory difficulty, increasing drowsiness and multiple vesicular skin lesions. Herpes simplex virus type-1 was isolated from skin lesions and a throat swab and herpes simplex virus type-1 antigen was detected in a liver biopsy sample. She recovered rapidly without any sequelae after treatment with intravenously administered acyclovir.