Fatal disseminated herpes simplex virus infection and hemorrhage in the neonate. Coagulation studies in a case and a review

Herpes simplex virus hepatitis after solid organ transplantation in adults

Twelve patients developed herpes simplex (HSV) hepatitis a median of 18 days after solid organ transplantation. This is earlier than cytomegalovirus hepatitis, which usually occurs 30-40 days after transplantation. Eight recipients (67%) died, and in seven, the diagnosis was made at autopsy or less than 48 h before death. Clinical manifestations associated with mortality were hypotension, disseminated intravascular coagulation (DIC), metabolic acidosis, gastrointestinal bleeding, and bacteremia. Laboratory abnormalities at diagnosis associated with mortality were high creatinine, low platelet counts, prolonged partial thromboplastin time, and a high percentage of band forms on the blood smear. Disseminated HSV disease was noted in four of six patients who had an autopsy and included involvement of lungs in three and the gastrointestinal tract in three. Five recipients developed DIC and all died. Pathologically, HSV hepatitis has two forms, focal and diffuse. All three patients with diffuse liver pathology died. However, three of seven with focal liver pathology survived with antiviral therapy, which suggests that early diagnosis and treatment may be lifesaving. None of these patients had received prophylactic acyclovir. It is possible that acyclovir prophylaxis may be able to prevent this disease.

Prevalence of genital herpes simplex infection and abnormal vaginal cytology in late pregnancy in asymptomatic patients

A study was undertaken to determine the prevalence of genital herpes simplex virus (HSV) infection in 809 asymptomatic, late pregnant women attending the antenatal clinic (ANC) at Ramathibodi Hospital. There was only one case where the cervico-vaginal swab specimen was positive for HSV by cultivation and the biotin-streptavidin enzyme-linked immunosorbent assay (B-SA ELISA), for detection of viral antigens. This gave a prevalence rate of 0.12%. The anti-HSV IgM in cord blood of the infant born to this mother was negative. The Papanicolaou (Pap) smear was performed in 554 cases, including the above patient, but none showed evidence of HSV infection. The high prevalence of lower genital tract infection in these subjects was noted in both Pap smear (31.05%) and wet preparation of the cervico-vaginal discharge (46.72%). Thus, examination of the cervico-vaginal discharge during late pregnancy should be of benefit to the patients, in revealing asymptomatic infections of the lower genital tract.

Viral diseases involving the liver

Even though HAV, HBV and HNANB viruses are responsible for most of the viral hepatitis cases, many other viruses have been reported to cause hepatic injury. These viruses may involve the liver, either as part of a systemic illness (e.g. EBV, CMV, HSV) or as the primary target organ (e.g. yellow fever virus, Lassa fever virus, Ebola virus). Clinically overt hepatocellular dysfunction is rare in such viral infections. Biochemical disturbance of hepatic functions shown, for example, by rises in AST and ALT, is a frequent event and indicates hepatic damage. Morphological changes of the liver include varying degrees of hepatic necrosis with a paucity of inflammatory activities. Intranuclear or cytoplasmic inclusion bodies may be characteristic findings in these diseases. Laboratory diagnosis depends upon serology and liver histology. Treatment is still largely supportive in most of these diseases, although recent trials of antiviral agents show promise against some viruses. Chronic sequelae, such as cirrhosis or hepatocellular cancer, are not encountered. More work is needed to elucidate the pathogenesis of hepatic injury in these illnesses.

Acute idiopathic thrombocytopenic purpura in children

Acute idiopathic thrombocytopenic purpura (ITP) characteristically follows a viral illness in preschool children. The exact role of viruses in the pathogenesis of this disorder remains uncertain, but the finding of markedly elevated levels of platelet-associated IgG serves to distinguish it from the chronic form of the disease and permits speculation on the mechanisms of platelet destruction. Although the spleen is important in both antibody production and platelet destruction, bone marrow synthesis of IgG has also been shown to be increased. The clinical course may be alarming, but mortality is low and prognosis excellent. Controversy has surrounded the role of steroids in the management of acute childhood ITP in retrospective studies. Controlled studies, however, indicate that thrombocytopenia is reversed sooner in treated patients. New assays for platelet-associated IgG offer new insights into this disorder and will allow delineation of acute and chronic disease at the time of diagnosis.

Disseminated Herpes simplex virus infection in ataxia-telangiectasia

The clinical and pathological features are described in a child with ataxia-telangiectasia, complicated by fatal disseminated herpes simplex virus infection. Herpes simplex virus was isolated from the patient's blood, and the histopathological findings in the skin, liver and adrenals were consistent with herpes simplex virus infection. The patient had a combined immune deficiency state, as a part of the ataxia-telangiectasia syndrome. She had imparied cellular immune response to herpes simplex virus and developed no antibodies against the virus. To our knowledge, this is the first fatal case of disseminated herpes simplex virus infection in ataxiatelangiectasia.

[Herpes simplex encephalitis in newborns. Treatment with 5-iodo-2'-deoxyuridin? (author's transl)]

Premature twins both affected with generalized herpes simplex infection including CNS involvement were treated with 5-Iodo-2'-deoxyuridin (IDU). Therapy was started 6 days and 5 days, respectively, after appearance of the first symptoms. Nevertheless both babies died, twin A at the age of 24 and twin B at the age of 28 days. Herpes virus was cultured from all organs in twin A. The literature shows a decrease in mortality in children treated with IDU for herpes simplex encephalitis. The percentage of survivors with ultimate severe CNS damage, however, is very high and remains in treated or untreated patients the same. The institution of IDU therapy in neonates with manifest HSV encephalitis is therefore not unequivocally justified.

Viral infections that affect the fetus

Several viral infections besides rubella are known to cause fetal anomalies and disease. Cytomegalovirus, for example, may adversely affect the fetus in a number of ways. Either herpesvirus or hepatitis B virus is transmissible from mother to offspring. Viruses whose potential for fetal harm is less clear are those of varicella, mumps, and influenza.

Disseminated intravascular coagulation in newborns. Survey and appraisal as exemplified in two case histories

Abruptio placenta, asphyxia, toxemia of pregnancy, sepsis and gen eralized viral infections are common causes of disseminated intra vascular coagulation in newborn infants. Prolonged prothrombin and partial thromboplastin times, low fibrinogen level, and throm bocytopenia are typical laboratory findings. The decision to give anticoagulation therapy with heparin rests upon bleeding or thrombosis or both, the question of intracranial bleeding, and the duration of the anticoagulation required. Significant bleeding or thrombosis of vessels of vital organs requires heparinization.