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Norvell JP, Blei AT, Jovanovic BD, Levitsky J. Herpes simplex virus hepatitis: an analysis of the published literature and institutional cases. Liver Transpl 2007; 13:1428-34. [PMID: 17902129 DOI: 10.1002/lt.21250] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- John P Norvell
- Department of Internal Medicine, Division of Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Abstract
Herpes simplex hepatitis is a treatable cause of acute hepatitis with a high mortality (41% to 79%). We present 4 adult patients who died of herpes simplex hepatitis and review another 70 patients (including pregnant women) from the literature to illustrate that herpes simplex hepatitis was only considered in the differential diagnosis in 26% to 33% of patients even though muco-cutaneous involvement was present in at least 70% of these patients. The presence of muco-cutaneous lesions in a patient with clinical symptoms and biochemical findings of acute hepatitis should raise the suspicion of herpes simplex hepatitis. Prompt treatment with acyclovir can be initiated within hours of admission in an attempt to prevent further hepatocellular damage in this potentially life-threatening infection.
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Affiliation(s)
- Shobha Sharma
- Emory University Hospital, Department of Pathology, Atlanta, Georgia 30322, USA.
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Takebe N, Yokoyama A, Akasaka Y, Ishii H, Miyaguchi S, Sata T, Hibi T, Oda M, Hata J, Tsuchiya M. Fatal herpes simplex hepatitis type 2 in a post-thymectomized adult. GASTROENTEROLOGIA JAPONICA 1993; 28:304-11. [PMID: 8486219 DOI: 10.1007/bf02779235] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The authors report an unusual case of herpes simplex type 2 (HSV) hepatitis which presented as part of a systemic HSV infection accompanied by disseminated intravascular coagulation (DIC). The patient was a 49-year-old Japanese male who three months prior to admission underwent surgical resection of his thymus for an invasive thymoma. Postoperatively, he received a course of chemotherapy which included prednisone, cyclophosphamide, vincristine, and pinorubicin. After discharge from the hospital, he was put on a maintenance dosage of prednisone and cyclophosphamide. Two weeks prior to this admission, the patient developed rhinorrhea, chills and general fatigue. Routine follow-up laboratory tests revealed markedly elevated liver enzymes which led to his immediate hospitalization. The tentative diagnosis on admission was fulminant hepatitis with DIC. The patient's condition steadily worsened during his hospitalization and acyclovir was initiated on the 4th hospital day due to the possibility of HSV hepatitis. He died on the same day. Histopathology performed on the liver at autopsy revealed hepatic inclusion bodies of HSV with positive immunohistochemical detection of the HSV type 2 antigen. Our case is the first report of HSV hepatitis associated with the removal of the thymus secondary to thymoma. It supports previous observations of disseminated HSV infection being prevalent in those patients with disorders of cell mediated immunity.
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Affiliation(s)
- N Takebe
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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Abstract
Herpes simplex virus (HSV) hepatitis is rare in adults, usually occurring in immunocompromised individuals and in otherwise healthy women in the third trimester of pregnancy. Three cases of HSV hepatitis occurring in pregnant women were diagnosed at our institution between 1981 and 1990. This diagnosis was not suspected clinically, and in each case was made on the basis of histology, immunoperoxidase studies, and viral cultures of liver tissue. Clinically, the patients had severe anicteric liver failure with markedly elevated serum aspartate aminotransferase and alanine aminotransferase levels; two of the three patients died. None had mucocutaneous lesions at the time of diagnosis. Histologically, two distinct patterns of necrosis and inflammation were seen. Two of the cases had well-demarcated foci of necrosis scattered randomly throughout the lobules with neutrophilic infiltration, giving the impression of abscess formation. Hepatocytes at the periphery of these areas of necrosis had enlarged nuclei with "ground-glass" inclusions; however, no Cowdry type A inclusions were seen. Rare multinucleated cells were present. Immunoperoxidase staining using antibodies to HSV was positive primarily in the hepatocytes with inclusions. The third case had diffuse, almost total hepatic necrosis with no viral inclusions and virtually no inflammatory response. This histologic pattern is similar to that seen in neonates with HSV infection. Immunoperoxidase studies in this case were negative; however, viral cultures were positive. While HSV hepatitis may be suspected or diagnosed on the basis of histology alone, viral cultures are an important adjunct since viral inclusions may be absent. Prompt diagnosis is important since antiviral therapy is now available.
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Affiliation(s)
- S M Jacques
- Department of Pathology, Hutzel Hospital, Detroit, MI 48201
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Kusne S, Schwartz M, Breinig MK, Dummer JS, Lee RE, Selby R, Starzl TE, Simmons RL, Ho M. Herpes simplex virus hepatitis after solid organ transplantation in adults. J Infect Dis 1991; 163:1001-7. [PMID: 1850439 PMCID: PMC2956417 DOI: 10.1093/infdis/163.5.1001] [Citation(s) in RCA: 84] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- S Kusne
- Department of Medicine, Graduate School of Public Health, University of Pittsburgh, Pennsylvania 15261
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Tomita T, Chiga M, Lenahan M, Balachandran N. Identification of herpes simplex virus infection by immunoperoxidase and in situ hybridization methods. VIRCHOWS ARCHIV. A, PATHOLOGICAL ANATOMY AND HISTOPATHOLOGY 1991; 419:99-105. [PMID: 1651584 DOI: 10.1007/bf01600223] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Seven cases of visceral herpes simplex virus (HSV) infection were observed in five cases of hematopoietic disease and in one case each of a newborn baby and a pregnant woman. These seven cases were studied with an immunoperoxidase method and in situ hybridization. In HSV lesions of squamous epithelium, the immunoperoxidase method using rabbit anti-human HSV revealed positive staining, mainly in the nucleus but with some cytoplasmic staining. DNA in situ hybridization revealed stronger positive staining in the nucleus. In HSV hepatitis positive staining was seen in the nucleus and cytoplasm, both by immunoperoxidase and in situ hybridization methods. In the newborn baby, HSV lesions were observed in the brain only, with numerous positive astrocytes identified by the immunoperoxidase method and a few positive astrocyte nuclei by in situ hybridization. Cultured human fetal fibroblasts from the lung were infected with HSV. The immunoperoxidase method revealed diffuse positive staining in the nucleus and in the cytoplasm whereas in situ hybridization revealed fibrillar positive staining in the nucleus only. Thus, the immunoperoxidase method using rabbit anti-human HSV can detect the presence of HSV protein more sensitively than in situ hybridization, probably because of the greater quantity of HSV protein compared with HSV DNA in infected cells.
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Affiliation(s)
- T Tomita
- Department of Pathology, University of Kansas Medical Center, Kansas City 66103
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Shlien RD, Meyers S, Lee JA, Dische R, Janowitz HD. Fulminant herpes simplex hepatitis in a patient with ulcerative colitis. Gut 1988; 29:257-61. [PMID: 3345937 PMCID: PMC1433304 DOI: 10.1136/gut.29.2.257] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A 16 year old girl with ulcerative colitis developed hepatitis with a high fever, leukopenia and a marked rise in serum transaminases without jaundice. There were no skin, oral, or genital lesions. Liver biopsy was precluded by abnormalities in coagulation. Postmortem examination of the liver by light and electron microscopy, culture, immunoperoxidase and immunofluorescent staining confirmed the diagnosis of hepatitis due to type 1 herpes simplex virus. Despite the rarity, this viral aetiology should be included in the differential diagnosis of all patients with severe hepatitis. The absence of mucocutaneous lesions should not exclude the diagnosis, especially when other clinical features are compatible.
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Affiliation(s)
- R D Shlien
- Department of Medicine, Mount Sinai School of Medicine, City University of New York, New York 10029
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Lebovics E, Thung SN, Schaffner F, Radensky PW. The liver in the acquired immunodeficiency syndrome: a clinical and histologic study. Hepatology 1985; 5:293-8. [PMID: 3979960 DOI: 10.1002/hep.1840050224] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We reviewed the clinical data and hepatic histologic findings of 25 patients with the acquired immunodeficiency syndrome who underwent 29 liver biopsies. Our experience indicates that the only hepatic feature characteristic of acquired immunodeficiency syndrome is serologic evidence of exposure to the hepatitis B virus. The most common histologic finding was macrovesicular steatosis. Granulomas appeared in seven patients and were due to mycobacterial disease (3 patients), histoplasmosis (1 patient), adverse reaction to sulfonamide (2 patients) and unknown causes (1 patient). The clinical indication for liver biopsy was not significantly different in the patients without or with granulomas or with granulomas secondary to mycobacteria or fungi. Mycobacteria were cultured from all histologically positive specimens and one histologically negative specimen. Liver biopsy should be performed in any patient with acquired immunodeficiency syndrome who has unexplained fever, hepatomegaly or abnormal results of serum biochemical liver tests, and all specimens should be stained and cultured for mycobacteria and fungi.
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Abstract
The case presented documents HSV hepatitis in a 41 year old caucasian male with a history of prolonged steroid treatment and recent irradiation for brain tumor recurrence. The fulminant nature of the hepatitis, accompanied by gastric ulcer hemorrhage, lead to his death within 24 hours of symptomatic manifestation. The diagnosis of HSV hepatitis was made postmortem. The etiology of the hepatitis was established by light microscopic identification of Cowdry type A intranuclear inclusion bodies, electron microscopic identification of virus particles, and the immunohistochemical detection of herpes simplex virus antigens.
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Walker DP, Longson M, Lawler W, Mallick NP, Davies JS, Johnson RW. Disseminated herpes simplex virus infection with hepatitis in an adult renal transplant recipient. J Clin Pathol 1981; 34:1044-6. [PMID: 7024324 PMCID: PMC494239 DOI: 10.1136/jcp.34.9.1044] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
A rare occurrence of disseminated herpes simplex virus infection with hepatitis in an adult renal transplant recipient is described.
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Bernuau J, Rueff B, Clauvel JP, Degott C, Perol Y, Benhamou JP. Non-inflammatory herpes simplex hepatitis in an adult with chronic neutropenia. LIVER 1981; 1:244-8. [PMID: 6294439 DOI: 10.1111/j.1600-0676.1981.tb00038.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We report the case of a young woman with chronic neutropenia, in whom hepatitis, extensive herpetic eruption and herpes simplex viremia developed after genital herpetic ulceration. Although severe liver necrosis was present, the patient's death did not result from hepatic failure. No inflammatory cell infiltration was found circumscribing the multiple necrotic foci in the liver. This absence of inflammatory cell infiltration reflects the host's inability to normally restrain herpes simplex virus dissemination and, in this patient, might be the consequence of chronic neutropenia.
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Buss DH, Scharyj M. Herpesvirus infection of the esophagus and other visceral organs in adults. Incidence and clinical significance. Am J Med 1979; 66:457-62. [PMID: 433952 DOI: 10.1016/0002-9343(79)91068-4] [Citation(s) in RCA: 133] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Ben-Zvi A, Soffer D, Yatziv S. Disseminated Herpes simplex virus infection in ataxia-telangiectasia. ACTA PAEDIATRICA SCANDINAVICA 1978; 67:667-70. [PMID: 696312 DOI: 10.1111/j.1651-2227.1978.tb17821.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Abstract
Liver disease is a common complication in renal transplant recipients. Several types of liver disease can occur. The most common are acute and chronic hepatitis. The variety of acute hepatitis include hepatitis A, hepatitis B, cytomegalovirus hepatitis, herpes simplex hepatitis and azathioprine hepatitis. The incidence of azathioprine hepatitis may not be as high as initially suggested. Chronic hepatitis is a serious problem because the disease seems to be progressive despite prednisone therapy. The causes of this chronic hepatitis are not fully known, although hepatitis B, cytomegalovirus and herpes simplex virus have been implicated. Discontinuation of azathioprine therapy has no appreciable effect on the course of chronic hepatitis.
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Yamada G, Feinberg LE, Nakane PK. Hepatitis B. Cytologic localization of virus antigens and the role of the immune response. Hum Pathol 1978; 9:93-109. [PMID: 344193 DOI: 10.1016/s0046-8177(78)80011-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Antigens of the hepatitis B virus have been localized within liver tissue by various immunologic, histochemical, and electron microscopic methods. The abundance and distribution of these virus antigens are in part determined by the host immune response. This interaction of immune mechanisms with the hepatitis B virus may be related to the pathogenesis and natural history of human hepatitis B virus infection.
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Faden HS, Bybee BL, Overall JC, lahey ME. Disseminated Herpesvirus hominis infection in a child with acute leukemia. J Pediatr 1977; 90:951-3. [PMID: 266071 DOI: 10.1016/s0022-3476(77)80566-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Holdsworth SR, Atkins RC, Scott DF, Hayes K. Systemic herpes simplex infection with fulminant hepatitis post-transplantation. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1976; 6:588-90. [PMID: 799503 DOI: 10.1111/j.1445-5994.1976.tb04002.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Immunosuppression for renal transplantation is associated with the risk of severe overwhelming infection with ubiquitous but normally relatively harmless micro-organisms. In recent years a number of adult cases of fatal hepatitis due to herpes simplex virus (HSV) infection have been reported. Nearly always immune deficiency was a significant factor. A case of fatal HSV infection with hepatitis following transplantation is reported. The case failed to respond to infusion with the antiviral agent cytosine arabinoside. The presentation, diagnosis and treatment of HSV fulminant hepatitis is discussed.
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Abstract
A primary infection with herpes simplex virus (HSV) occurs at some time in the life of almost every member of the population, especially among those living in crowded, unsanitary conditions. In many cases the lesions are subclinical, and in most cases they are self-limited even when clinical. In a few patients, such as the newborn infant, the patient with concomitant eczema, or the patient with reduced immunity, the primary infection may become severe, generalized, and life-threatening. Type 1 HSV has a predilection for a number of sites, including the oral cavity, the eye, and the skin; and type 2 HSV has a predilection for the genital area and for the newborn.
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Sutton AL, Smithwick EM, Seligman SJ, Kim DS. Fatal disseminated herpesvirus hominis type 2 infection in an adult with associated thymic dysplasia. Am J Med 1974; 56:545-53. [PMID: 4361959 DOI: 10.1016/0002-9343(74)90487-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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