Fulminant herpes hepatitis in an immunocompetent pregnant woman: CT imaging features

Newer developments in viral hepatitis: Looking beyond hepatotropic viruses

Viral hepatitis in the entirety of its clinical spectrum is vast and most discussion are often restricted to hepatotropic viral infections, including hepatitis virus (A to E). With the advent of more advanced diagnostic techniques, it has now become possible to diagnose patients with non-hepatotropic viral infection in patients with hepatitis. Majority of these viruses belong to the Herpes family, with characteristic feature of latency. With the increase in the rate of liver transplantation globally, especially for the indication of acute hepatitis, it becomes even more relevant to identify non hepatotropic viral infection as the primary hepatic insult. Immunosuppression post-transplant is an established cause of reactivation of a number of viral infections that could then indirectly cause hepatic injury. Antiviral agents may be utilized for treatment of most of these infections, although data supporting their role is derived primarily from case reports. There are no current guidelines to manage patients suspected to have viral hepatitis secondary to non-hepatotropic viral infection, a gap that needs to be addressed. In this review article, the authors analyze the common non hepatotropic viral infections contributing to viral hepatitis, with emphasis on recent advances on diagnosis, management and role of liver transplantation.

A Surprising Cause of Liver Abscesses in a Post-Chemotherapy Patient: Herpes Simplex Virus

Herpes simplex virus (HSV) hepatitis is a rare complication of HSV infection, and a rare cause of hepatitis. It is often fatal, especially if the diagnosis and treatment are delayed. Herein, we describe the case of a 31-year-old female with a history of receiving cytotoxic cancer chemotherapy five months prior who presented with a one-week history of worsening abdominal pain and fever. She was noted to have an outbreak of genital herpes at the time of presentation. Computed tomography (CT) scan of the abdomen showed innumerable hypodensities compatible with hepatic micro-abscesses. A specimen from a subsequent liver biopsy revealed HSV-type cytopathic changes and nuclear staining with an anti-HSV immunohistochemical stain. She was initially started on high-dose oral valacyclovir for genital herpes and was noted to have rapid clinical improvement prior to the histopathologic diagnosis of HSV hepatitis. She achieved full recovery while on oral valacyclovir. This is the first reported case of HSV hepatitis treated with oral valacyclovir and the third reported case of HSV hepatitis mimicking pyogenic abscesses on abdominal imaging. With the high mortality rate associated with HSV hepatitis, one should consider the diagnosis in all patients with multifocal liver lesions of unknown etiology, especially if genital herpes is present at the time of presentation, or in patients who are immunocompromised.

Fetal androgen exposure is a determinant of adult male metabolic health

Androgen signalling is a critical driver of male development. Fetal steroid signalling can be dysregulated by a range of environmental insults and clinical conditions. We hypothesised that poor adult male health was partially attributable to aberrant androgen exposure during development. Testosterone was directly administered to developing male ovine fetuses to model excess prenatal androgenic overexposure associated with conditions such as polycystic ovary syndrome (PCOS). Such in utero androgen excess recreated the dyslipidaemia and hormonal profile observed in sons of PCOS patients. 1,084 of 15,134 and 408 of 2,766 quantifiable genes and proteins respectively, were altered in the liver during adolescence, attributable to fetal androgen excess. Furthermore, prenatal androgen excess predisposed to adolescent development of an intrahepatic cholestasis-like condition with attendant hypercholesterolaemia and an emergent pro-fibrotic, pro-oxidative stress gene and protein expression profile evident in both liver and circulation. We conclude that prenatal androgen excess is a previously unrecognised determinant of lifelong male metabolic health.

A literature review of herpes simplex virus hepatitis in pregnancy

Purpose: Hepatitis due to herpes simplex virus (HSV) during pregnancy is rare, it is often not included in the differential disease. However, hepatitis leads to maternal death; hence, early diagnosis is necessary. Hepatic enzyme elevation in late pregnancy is often associated with obstetric-related diseases, such as acute gestational fatty liver and HELLP syndrome (hemolytic anemia, elevated liver enzymes, low platelet count). These pregnancy-related diseases often improve maternal condition after completion of pregnancy, but in patients with HSV hepatitis, invasive treatment, such as cesarean section, may lead to deterioration of maternal condition after completion of pregnancy. A systematic review was conducted to extract necessary factors to avoid maternal death caused by herpetic hepatitis.Methods: In 24 cases reported since 1991, age, onset gestational weeks, initial symptoms, days from onset of symptoms to consultation, diagnosis method, treatment method, maximum liver escape enzyme value during hospitalization, bilirubin value, international normalized ratio value, and fetal/neonatal prognosis were extracted, and the relationship between maternal death group (n = 6) and maternal alive group (n = 18) was statistically analyzed.Results: Fever as an initial symptom was observed in all cases. Maternal death did not occur in patients administered with acyclovir (ACV) as empiric therapy. No difference was found between the two groups in other factors.Conclusion: Early diagnosis and treatment of herpetic hepatitis during pregnancy are important, as well as administration of empiric ACV concurrently with noninvasive diagnosis when a pregnant woman has elevated liver enzyme accompanied by fever in late pregnancy.

Hepatitis caused by herpes viruses: A review

Herpes virus hepatitis varies in presentation, ranging from asymptomatic to acute liver failure, in both immunocompetent and immunocompromised individuals. Hepatitis caused by the Herpesviridae family is uncommon and usually results in mild disease. It is also often self-limiting, although in certain populations especially immunosuppressed patients, it can cause severe infections, leading to acute to fulminant hepatic failure. In addition, some isolated cases of fulminant disease in immunocompetent individuals have been reported. As the presentation is frequently non-specific, it is important to maintain a high level of suspicion for these viral etiologies and start empiric therapy with antiviral agents as soon as possible. Liver transplantation is the last resort. Mortality remains high in fulminant hepatic failure caused by Herpesviridae without liver transplantation. Here we review the literatures on hepatitis caused by three members of the Herpesviridae family, cytomegalovirus, Epstein-Barr virus and herpes simplex virus to discuss the epidemiology, diagnostic methods, clinical features and current management, and also to determine which aspects need to be investigated in further detail. Herpesviridae-mediated acute liver failure is rare but is associated with a poor prognosis, even after early treatment.

Dual infection in pregnancy: Disseminated Mycoplasma hominis and necrotizing herpes simplex 2 hepatitis

Mycoplasma hominis is part of the genitourinary flora in sexually active people and can cause disseminated infection in immunocompromised patients. We describe a rare case of an immunocompetent pregnant woman with simultaneous necrotizing HSV hepatitis and disseminated M. hominis infection. Detection of M. hominis and antimicrobial susceptibility testing of this fastidious organism in the clinical laboratory is discussed.

Empirical treatment with parenteral acyclovir in a child with herpes simplex virus hepatitis and acute lymphoblastic leukemia

Introduction

Hepatitis secondary to Herpes Simplex Virus (HSV) infection is a complication that often leads to fatal hepatic failure. Early treatment with the anti-viral drug, acyclovir, is life-saving. In view of the non-specific nature of the signs and symptoms associated with HSV hepatitis, diagnosis is often made late during the course of the disease; a factor that largely contributes to the high mortality rate of this treatable disease complication. There is thus a growing consensus in the field to initiate empirical treatment with acyclovir once suspicion of HSV hepatitis is raised even before reaching a conclusive diagnosis.

Presentation of case

We present clinical evidence on the benefit of starting empirical acyclovir treatment on the outcome of patients suffering from HSV hepatitis. We report two cases of HSV hepatitis in children with cancer. One case presented with fulminant hepatitis which was fatal and the diagnosis was only reached post mortem. In the second case, there was enough suspicion of HSV hepatitis to start early empirical acyclovir therapy. The diagnosis was confirmed 48 hours following the initiation of treatment and the early intervention with anti-virals proved to be life-saving.

Discussion

In both cases above, the following symptoms were shared; fever, elevated transaminase levels and mucositis without clear cutaneous lesions. HSV hepatitis should thus be considered in the differential diagnosis of immuonocomprimised patients exhibiting the above symptoms.

Conclusion

Due to the frequent delay in HSV diagnosis and the safety of acyclovir, we recommend empirically administering acyclovir in patients suspected of HSV hepatitis.

A fatal case of herpes simplex virus hepatitis in a pregnant patient

We present a middle aged pregnant woman who developed signs and symptoms of acute liver failure and was found to have herpes simplex virus hepatitis. Patient had an emergent delivery and was started on antiviral therapy, but unfortunately due to the severity of her liver failure, she passed away. The importance of reporting this case is to emphasize on the importance of considering herpes simplex infection in pregnant women who present with acute liver failure, and the importance of early administration of antiviral therapy.

Herpes Simplex Virus Hepatitis in an Immunocompetent Host Resembling Hepatic Pyogenic Abscesses

Herpes simplex virus (HSV) hepatitis represents a rare complication of HSV infection, which can progress to acute liver failure and, in some cases, death. We describe an immunocompetent 67-year-old male who presented with one week of fever and abdominal pain. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen showed multiple bilobar hepatic lesions, some with rim enhancement, compatible with liver abscesses. Subsequent liver biopsy, however, revealed hepatocellular necrosis, HSV-type intranuclear inclusions, and immunostaining positive for herpes virus type 2 (HSV-2). Though initially treated with broad-spectrum antibiotics, following histologic diagnosis of HSV hepatitis, the patient was transitioned to intravenous acyclovir for four weeks and he achieved full clinical recovery. Given its high mortality and nonspecific presentation, one should consider HSV hepatitis in all patients with acute hepatitis with multifocal hepatic lesions of unknown etiology. Of special note, this is only the second reported case of HSV liver lesions mimicking pyogenic abscesses on CT and MRI.

Pregnancy and liver disease

Pregnancy associated liver diseases affect up to 3% of pregnant women and are the most frequent cause of liver dysfunction in pregnancy. When severe, they are associated with significant morbidity and mortality for both mother and infant. A rapid evaluation to distinguish them from non-pregnancy related liver dysfunction is essential, in order to facilitate appropriate management. Liver disease unrelated to pregnancy can present de novo in pregnancy, or pregnancy can occur in women with preexisting liver pathology (Table 1). Research and subsequent advances in medical care have resulted in improved but still not satisfactory maternal and fetal outcomes. In this review we provide an overview of the liver diseases specific to the pregnant state and an update on their pathogenesis, treatment and outcomes. The risks of pregnancy in women with pre-existent liver pathology is detailed and recent advances in our understanding of specific risks and outcomes are discussed.

Antiviral-resistant fulminant herpes hepatitis in pregnancy

Fulminant herpes hepatitis with disseminated extrahepatic involvement in pregnancy is rare and carries a high mortality risk. Although acyclovir remains standard first-line therapy, effective management of acyclovir-resistant disseminated herpes simplex virus (HSV) in pregnancy remains elusive. We present a case of disseminated HSV resistant to both acyclovir and foscarnet, the first double-agent resistant case in pregnancy reported in the literature to date. In this case, therapeutic delivery was the ultimate treatment resulting in full recovery.

Acute Interstitial Nephritis Proteinuria and Herpes Simplex Virus Hepatitis in Pregnancy Mimic HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets)

Elevated transaminases, hemolysis, and thrombocytopenia in pregnancy are most often caused by a preeclampsia variant-HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). In atypical cases, it is important to consider other causes, such as herpes simplex virus (HSV) hepatitis. Acute interstitial nephritis (AIN)-induced proteinuria can make distinguishing HELLP from its mimics more difficult. A 43-year-old G4P3 gestational carrier at 28 weeks had abnormal laboratory findings consistent with HELLP, including proteinuria. However, she was normotensive and febrile, prompting an investigation into other possible causes of her signs and symptoms. She ultimately was diagnosed with disseminated HSV infection, started on definitive therapy, and allowed to continue her pregnancy to term. The proteinuria was attributed to AIN. AIN can cause proteinuria in the critically ill pregnant patient. When mimics of HELLP syndrome, such as disseminated HSV infection, are the cause of critical illness, the presence of AIN-induced proteinuria may falsely implicate a hypertensive disorder of pregnancy, resulting in iatrogenic premature delivery of the fetus and failure to initiate definitive potential lifesaving treatment.

Fulminant gestational hepatitis due to primary herpes simplex type 2 infection: use of serum HSV polymerase chain reaction for noninvasive diagnosis

Acute gestational hepatitis from herpes simplex virus (HSV) infection is a rare but potentially life-threatening condition. We present the first reported case of primary HSV type 2 hepatitis in a pregnant woman who was diagnosed by detection of HSV-2 viremia via real-time polymerase chain reaction. The patient was successfully treated with acyclovir and delivered a healthy infant.

Chronic asymptomatic pancreatic hyperenzymemia is a benign condition in only half of the cases: a prospective study

OBJECTIVE

Prospectively to evaluate patients with chronic asymptomatic pancreatic hyperenzymemia in order to identify possible pancreatic and non-pancreatic diseases.

MATERIAL AND METHODS

Seventy-five asymptomatic subjects with long-standing pancreatic hyperenzymemia (45 M, 30 F; mean age+/-SD 51.5+/-16.0 years, range 19-78 years, mean duration+/-SD of pancreatic hyperenzymemia 14.7+/-7.0 months, range 7-34 months) and normal ultrasonographic evaluation were included in this study. The subjects enrolled were carefully interviewed and prospectively evaluated. All patients underwent blood screening. An additional abdominal ultrasound was also carried out and, if considered necessary, other imaging and endoscopic evaluation procedures were used.

RESULTS

The follow-up of the patients after enrollment in the study was 3.3+/-1.8 years (mean+/-SD). In 38 patients (50.7%), pancreatic or extrapancreatic disease was diagnosed: 20 patients had chronic pancreatitis, 1 had autoimmune chronic pancreatitis, 1 had a benign cyst of the pancreas, 2 had serous cystadenomas, 5 had an intraductal papillary mucinous tumor of the pancreas, 3 had a ductal pancreatic adenocarcinoma, 4 patients had chronic viral hepatitis, and 2 had Crohn's disease. In 37 subjects (49.3%), no pancreatic or extrapancreatic diseases were found (3 subjects had macroamylasemia, 3 had familial hyperenzymemia, 31 had chronic non-pathological pancreatic hyperenzymemia).

CONCLUSIONS

Subjects having an increase of either amylase or lipase serum levels should undergo a thorough diagnostic work-up prior to establishing the existence of chronic non-pathological pancreatic hyperenzymemia.

Hyperamylasaemia and/or hyperlipasaemia: incidence and underlying causes in hospitalized patients with non-pancreatic diseases

OBJECTIVE

There are no recommendations on how to proceed in patients with increased pancreatic enzyme activities but non-pancreatic diseases. The objective of this study was to investigate prospectively in a general medical hospital the incidence, causes and clinical impact of hyperamylasaemia and/or hyperlipasaemia in these patients.

MATERIAL AND METHODS

During a 4-month period in 2004, amylase and lipase activities were measured in all patients (n, 1765) admitted to the Department of Internal Medicine of the Municipal Clinic of Lüneburg, Germany. Patients with increased enzyme activities underwent abdominal ultrasonography and, if inconclusive, other imaging procedures.

RESULTS

Amylase and/or lipase activities were increased in 140 (8%) patients with non-pancreatic diseases: amylase in 29 cases (21%) and 1 case (1%)<3 and>3 times the upper limit of normal, respectively, lipase in 120 cases (86%) and 6 cases (4%)<3 and>3 times, respectively. In 53 (38%) patients no further imaging studies could be performed. In the remaining 87 patients amylase was increased in 18 patients (21%) and lipase in 3 patients (3%). The pancreas was normal on imaging procedures in 77 (89%) patients and abnormal in 10 (11%) (chronic pancreatitis: 4, small cystic lesions: 6). The cystic lesions were mostly located in the pancreas head, probably corresponding to branch-duct intraductal papillary mucinous neoplasm.

CONCLUSIONS

Increased pancreatic enzyme activities occur in 8% of hospitalized patients with non-pancreatic diseases, but pancreatic abnormalities will be found in only a few (11%), which are unlikely to need further investigation or therapy. Therefore, routine analysis of amylase or lipase activities in patients with non-pancreatic diseases is not indicated.

Multimodality imaging of hepato-biliary disorders in pregnancy: a pictorial essay

Hepato-biliary disorders are rare complications of pregnancy, but they may be severe, with high fetal and maternal morbidity and mortality. Imaging is, therefore, essential in the rapid diagnosis of some of these conditions so that appropriate, life-saving treatment can be administered. This pictorial essay illustrates the multimodality imaging features of pregnancy-induced hepato-biliary disorders, such as acute fatty liver of pregnancy, preeclamsia and eclampsia, and HELLP syndrome, as well as those conditions which occur in pregnancy but are not unique to it, such as viral hepatitis, Budd-Chiari syndrome, focal hepatic lesions, biliary sludge, cholecystolithiasis, and choledocholithiasis.

Congenital anomalies and variations of the bile and pancreatic ducts: magnetic resonance cholangiopancreatography findings, epidemiology and clinical significance

PURPOSE

The objective of this paper is to document the magnetic resonance cholangiopancreatography (MRCP) findings and the epidemiology of congenital anomalies and variations of the bile and pancreatic ducts and to discuss their clinical significance.

MATERIALS AND METHODS

Three-hundred and fifty patients of both sexes (150 females, 200 males, age range 0-76 years, average age 38 years) underwent MRCP for clinically suspected lithiasic, neoplastic or inflammatory disease of the bile and pancreatic ducts. Patients were imaged with a 1.5-T superconductive magnet (Magnetom Vision, Siemens, Erlangen, Germany), a four-channel phased-array body coil, breath-hold technique, with multislice T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE), MIP reconstructions, and a single-shot T2-weighted turbo-spin-echo sequence rapid acquisition with relaxation enhancement (RARE) with different slice thicknesses. Studies in oncological patients were completed with fat saturation 3D T1 gradient-echo sequences during the intravenous injection of gadolinium diethylene triamine pentaacetate acid (DTPA) (0.2 ml/kg).

RESULTS

MRCP demonstrated recurrent and therefore normal bile and pancreatic ducts in 57% of patients. In the remaining 42.3%, it documented anatomical variants (41%) and congenital anomalies (1.3%). Variants of the intrahepatic bile duct were seen in 21% of cases: crossover anomaly (6.7%), anterior branch of the right hepatic duct draining the IV and VII segments that flow together with the left bile duct (3.1%) and anterior and posterior branches of the right hepatic duct that flow together with the common hepatic duct (3.3%). Variants of the extrahepatic bile ducts were present in 8.8% of patients: low insertion of the cystic duct into the common hepatic duct (4.5%), emptying of the cystic duct into the right hepatic duct (2.7%) and a second-order large branch draining into the cystic duct (1.6%). MRCP identified a double gall bladder in 3% of patients and anatomical variants of the biliopancreatic system in 8.2%: pancreas divisum (5.2%) and a long sphincter of Oddi (3%). Finally, congenital anomalies were diagnosed in 1.3% of cases: bile duct cysts (0.3%), atresia of the bile ducts (0.3%) and multiple biliary hamartomatosis (0.7%).

CONCLUSIONS

The congenital anomalies and anatomical variants of the bile and pancreatic ducts present a complex spectrum of frequent alterations, which are worthy of attention in both the clinical and surgical settings and are readily identified by MRCP.

Herpes simplex virus hepatitis: an analysis of the published literature and institutional cases

Hepatitis is a rare complication of herpes simplex virus (HSV), often leading to acute liver failure (ALF), liver transplantation (LT), and/or death. Our aim was to identify variables associated with either survival or progression (death/LT), based on an analysis of cases in the literature and our institution. A total of 137 cases (132 literature, 5 institutional) of HSV hepatitis were identified. The main features at clinical presentation were fever (98%), coagulopathy (84%), and encephalopathy (80%). Rash was seen in less than half of patients. Most cases (58%) were first diagnosed at autopsy and the diagnosis was suspected clinically prior to tissue confirmation in only 23%. Overall, 74% of cases progressed to death or LT, with 51% in acyclovir-treated patients as compared to 88% in the untreated subjects (P=0.03). Variables on presentation associated with death or need for LT compared to spontaneous survival: male gender, age>40 yr, immunocompromised state, ALT>5,000 U/L, platelet count<75x10(3)/L, coagulopathy, encephalopathy, and absence of antiviral therapy. In conclusion, HSV hepatitis has a high mortality and is often clinically unsuspected. Patients who are male, older, immunocompromised, and/or presenting with significant liver dysfunction are more likely to progress to death and should thus be evaluated for LT early. Based on the frequent delay in HSV diagnosis, low risk-benefit ratio, and significantly improved outcomes, empiric acyclovir therapy for patients presenting with ALF of unknown etiology is recommended until HSV hepatitis is excluded.

Pancreatic adenocarcinoma: MDCT versus MRI in the detection and assessment of locoregional extension

PURPOSE

To compare dynamic-contrast enhanced multirow detector computed tomography (MDCT) including multiplanar reformatted images (MPR) and magnetic resonance imaging (MRI) including magnetic resonance cholangiopancreatography images for the detection and assessment of locoregional extension of pancreatic adenocarcinoma.

MATERIALS AND METHODS

Twenty-four patients with and 21 patients without pancreatic adenocarcinoma underwent triple-phase MDCT and MRI. Three radiologists independently attempted to detect pancreatic adenocarcinoma and assess locoregional extension in 3 sessions. First session involved MDCT images. In the second session, radiologists had access to coronal and sagittal MPR images together with the axial images (MDCT + MPR). Third session involved MR images. Results were compared with surgical findings using receiver operating characteristic analysis and kappa statistics.

RESULTS

Regarding tumor detection, MDCT + MPR had a significantly higher value for areas under the curve (0.96 +/- 0.02) at receiver operating characteristic analysis compared with those of MRI (0.90 +/- 0.03) and MDCT (0.85 +/- 0.04). MDCT + MPR had the highest mean sensitivity (96%), and MRI had the highest mean specificity (98%). For locoregional extension, MDCT + MPR showed the highest kappa values of the study for all factors evaluated (range, 0.63-0.86).

CONCLUSIONS

In conclusion, multiphasic MDCT imaging with MPR images was superior to multiphasic MDCT imaging without MPR images and to comprehensive MRI employing 2-D sequences and magnetic resonance cholangiopancreatography for both the detection and assessment of locoregional extension of pancreatic adenocarcinomas. MRI might be used for further lesion characterization regarding its high specificity.

The use of radiographic modalities to diagnose infection in pregnancy

The usefulness of sonography, plain film, CT, and MRI in diagnosing infections in pregnancy is discussed. Imaging modality choices for specific clinical indications in pregnancy are reviewed. The overall safety of most techniques in pregnancy is emphasized.