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Alexander V, Benjamin SJ, Subramani K, Sathyendra S, Goel A. Acute liver failure in pregnancy. Indian J Gastroenterol 2024; 43:325-337. [PMID: 38691240 DOI: 10.1007/s12664-024-01571-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/09/2024] [Indexed: 05/03/2024]
Abstract
Liver function abnormalities are noted in a minority of pregnancies with multiple causes for the same. A small proportion of these develop severe liver injury and progress to acute liver failure (ALF). There is a discrete set of etiology for ALF in pregnancy and comprehensive understanding will help in urgent evaluation. Certain diseases such as acute fatty liver of pregnancy, hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome and pre-eclampsia are secondary to pregnant state and can present as ALF. Quick and targeted evaluation with urgent institution of etiology-specific management, especially urgent delivery in patients with pregnancy-associated liver diseases, is the key to avoiding maternal deaths. Pregnancy, as also the fetal life, imparts a further layer of complication in assessment, prognosis and management of these sick patients with ALF. Optimal management often requires a multidisciplinary approach in a well-equipped centre. In this review, we discuss evaluation, assessment and management of pregnant patients with ALF, focussing on approach to pregnancy-associated liver diseases.
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Affiliation(s)
- Vijay Alexander
- Department of Hepatology, Christian Medical College, Vellore 632 004, India
| | - Santosh J Benjamin
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore 632 004, India
| | - Kandasamy Subramani
- Division of Critical Care, Christian Medical College, Vellore 632 004, India
| | - Sowmya Sathyendra
- Department of Obstetric Medicine, Christian Medical College, Vellore 632 004, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore 632 004, India.
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Biswas S, Kumar R, Shalimar, Acharya SK. Viral hepatitis-induced acute liver failure. Indian J Gastroenterol 2024; 43:312-324. [PMID: 38451383 DOI: 10.1007/s12664-024-01538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 03/08/2024]
Abstract
Viral hepatitis-induced acute liver failure (ALF) is a preventable cause for liver-related mortality worldwide. Viruses are the most common cause for ALF in developing nations in contrast to the west, where acetaminophen is largely responsible. Viruses may be hepatotropic or affect the liver secondary to a systemic infection. In tropical countries, infections such as leptospirosis, scrub typhus and malaria can mimic the symptoms of ALF. Differentiating these ALF mimics is crucial because they require etiology-specific therapy. Treatment of viral hepatitis-induced ALF is two-pronged and directed towards providing supportive care to prevent organ failures and antiviral drugs for some viruses. Liver transplantation (LT) is an effective modality for patients deteriorating despite adequate supportive care. Early referral and correct identification of patients who require a transplant are important. Liver support devices and plasma exchange have evolved into "bridging modalities" for LT. Preventive strategies such as hand hygiene, use of clean and potable water and inclusion of vaccines against viral hepatitis in the national program are simple yet very effective methods focusing on the preventive aspect of this disease.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, 801 507, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
| | - Subrat Kumar Acharya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
- KIIT University, Bhubaneswar, 751 024, India
- Fortis Escorts Digestive and Liver Institute, Okhla, New Delhi, 110 025, India
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Mularoni A, Cona A, Ribeiro Dias L, Bulati M, Busà R, Castelbuono S, Lo Porto D, Pietrosi G, Liotta R, Conaldi PG, Grossi PA, Luppi M. Cytokine storm and severe hepatitis in pregnancy due to herpes simplex virus 2. Infection 2024; 52:259-263. [PMID: 37759073 PMCID: PMC10811078 DOI: 10.1007/s15010-023-02092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/27/2023] [Indexed: 09/29/2023]
Abstract
CASE PRESENTATION A pregnant woman developed hepatitis due to a herpes simplex virus 2 primary infection with a severe systemic inflammatory response. Treatment with acyclovir and human immunoglobulin was given and both mother and baby survived. PURPOSE We provide the first description of the inflammatory response associated with herpetic hepatitis in pregnancy.
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Affiliation(s)
- Alessandra Mularoni
- Unit of Infectious Diseases, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Via Tricomi 5, 90127, Palermo, Italy
| | - Andrea Cona
- Unit of Infectious Diseases, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Via Tricomi 5, 90127, Palermo, Italy.
| | - Lùcia Ribeiro Dias
- Unit of Infectious Diseases, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Via Tricomi 5, 90127, Palermo, Italy
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Matteo Bulati
- Department of Research, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Rosalia Busà
- Department of Research, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Salvatore Castelbuono
- Department of Research, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Davide Lo Porto
- Unit of Infectious Diseases, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Via Tricomi 5, 90127, Palermo, Italy
| | - Giada Pietrosi
- Department for the Treatment and Study of Abdominal Disease and Abdominal Transplantation, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Rosa Liotta
- Pathology Unit, Department of Diagnostic and Therapeutic Services, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Pier Giulio Conaldi
- Department of Research, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Paolo Antonio Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, 41124, Modena, Italy
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4
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Lamps LW. A Pattern-Based Approach to Hepatic Infections. Mod Pathol 2023; 36:100239. [PMID: 37307875 DOI: 10.1016/j.modpat.2023.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023]
Abstract
The evaluation of liver biopsies for infection can be a challenging and frustrating situation for diagnostic pathologists as well as clinicians. Patients often present with nonspecific symptoms, such as fever and elevated transaminases, leading to a broad differential diagnosis that typically includes malignancy and noninfectious inflammatory diseases in addition to infections. A pattern-based histologic approach can be extremely helpful in both making a diagnosis and guiding the next steps for the evaluation of the pathology specimen as well as the patient. This review discusses several of the more commonly encountered histologic patterns associated with hepatic infectious diseases, the most common pathogens with which they are associated, and helpful ancillary studies.
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Affiliation(s)
- Laura W Lamps
- Department of Pathology and Clinical Laboratories, University of Michigan, Ann Arbor, Michigan.
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Azeem A, Baartman B, Conrady CD, Meier JL, El-Herte R. Herpes simplex virus dissemination with necrotizing hepatitis following Descemet membrane endothelial keratoplasty. BMC Infect Dis 2023; 23:465. [PMID: 37438705 DOI: 10.1186/s12879-023-08414-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Corneal transplants are the most common type of transplant and increasing in frequency. Donor cornea tissues are a rare source of herpes simplex virus (HSV) transmission and not routinely tested for presence of HSV. Donor graft-to-recipient transmission typically causes graft failure and anterior uveitis, and extra-ocular HSV disease has not been previously reported. We present a case of HSV transmission from donor cornea tissue that nearly cost the corneal transplant recipient his life. CASE REPORT An elderly immunocompetent man developed an acute illness 10 days after having donor corneal tissue implanted in a Descemet membrane endothelial keratoplasty (DMEK). He was found to have HSV necrotizing hepatitis per liver biopsy, trilineage cytopenia, rhabdomyolysis, acute kidney failure, altered mental status, early-stage hemophagocytic lymphohistiocytosis (HLH), and donor corneal tissue implant infection resulting in graft failure and anterior uveitis. HSV DNA was detected in cerebral spinal fluid, peripheral blood, explanted donor corneal tissue, and anterior chamber fluid (220 million HSV DNA copies per mL). HSV-1 seroconversion denoted a primary HSV infection, and the patient had no other risk factor for HSV acquisition. Early recognition of HSV dissemination prompting treatment with intravenous acyclovir, as well as a short course of HLH-directed therapy, resolved the systemic illness. Vision was restored to near normal by replacement of the infected corneal graft with new donor DMEK tissue in conjunction with intravitreal foscarnet treatment. CONCLUSION Awareness of the potential risk of donor cornea tissue transmitting HSV and leading to life-threatening HSV disease is paramount to early diagnosis and treatment. The role of donor cornea tissue in HSV transmission and disease merits additional attention and investigation.
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Affiliation(s)
- Ahad Azeem
- Department of Medicine, Creighton University School of Medicine and CHI Health, Omaha, NE, 68105, USA
| | | | - Christopher D Conrady
- Departments of Ophthalmology, Pathology, and Microbiology, Medical Center, University of Nebraska, Omaha, NE, 68198, USA
| | - Jeffery L Meier
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, 52246, USA.
- Division of Infectious Diseases, Department of Internal Medicine, Department of Epidemiology, College of Public Health, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA.
| | - Rima El-Herte
- Division of Infectious Diseases, Department of Medicine, Creighton University School of Medicine and CHI Health, Omaha, NE, 68124, USA.
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Van Wagoner N, Qushair F, Johnston C. Genital Herpes Infection: Progress and Problems. Infect Dis Clin North Am 2023; 37:351-367. [PMID: 37105647 DOI: 10.1016/j.idc.2023.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Genital herpes (GH) is a sexually transmitted infection causing recurrent, self-limited genital, buttock, and thigh ulcerations. Symptoms range from unrecognized or mild to severe with frequent recurrences. Herpes simplex viruses (HSV) type-1 or type-2 cause GH. HSV establishes latency in sacral ganglia and causes lifelong infection. Viral reactivation leads to genital ulceration or asymptomatic shedding which may lead to transmission. HSV infection during pregnancy can cause fulminant hepatitis and neonatal transmission. Severe and atypical manifestations are seen in immunocompromised people. Guanosine analogs treat symptoms and prevent recurrences, shedding, and transmission. Novel preventive and therapeutic strategies are in development.
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Affiliation(s)
- Nicholas Van Wagoner
- Division of Infectious Diseases, Department of Medicine, University of Alabama Heersink School of Medicine, VH 102A, 1720 2nd Avenue South, Birmingham, AL 35294, USA.
| | - Fuad Qushair
- University of Alabama Heersink School of Medicine, 1720 2nd Avenue South, Birmingham, AL 35294, USA
| | - Christine Johnston
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, 325 9th Avenue Box 359928, Seattle, WA 98104, USA
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Nguyen VV, Koro K, Coffin CS, Wang W, Syeda N, Meatherall B, Lee SS. Herpes simplex virus hepatitis in a renal transplant recipient seronegative pre-transplant. CANADIAN LIVER JOURNAL 2022; 5:530-534. [PMID: 38144412 PMCID: PMC10735198 DOI: 10.3138/canlivj-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 03/25/2022] [Accepted: 03/27/2022] [Indexed: 12/26/2023]
Abstract
BACKGROUND: Herpes simplex virus (HSV) is a rare cause of acute viral hepatitis but has high mortality rates and primarily affects immunocompromised hosts. We report a case of HSV hepatitis in a 20-year-old female kidney transplant recipient who had 1000-fold elevations in transaminases on post-transplant day 14, and the strategies employed for diagnoses and treatment. METHODS: Routine laboratory, serological, and molecular viral testing was completed, and she underwent a bone marrow biopsy given initial suspicion of hemophagocytic lymphohistiocytosis (HLH). HSV serologic results and high transaminases triggered a liver biopsy. RESULTS: The patient presented with elevated transaminases (ALT 1731 U/L and AST 1400) and ferritin (1431 μg/L). Transaminases and ferritin peaked with an ALT of 6609 U/L, AST of 6525 U/L, and ferritin >50000 μg/L. Bone marrow biopsy revealed no definitive HLH. HSV-DNA PCR of blood was positive, and she was empirically started on intravenous acyclovir 10 mg/kg 3 times per day. Liver biopsy confirmed the histological diagnosis of HSV hepatitis. CONCLUSIONS: Given the high mortality rates associated with HSV hepatitis, it is crucial to determine pre-transplant HSV status, initiate appropriate antiviral prophylaxis, and to have a low threshold for investigating for HSV hepatitis and initiating treatment in patients with a suspected diagnosis.
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Affiliation(s)
- Vivian V Nguyen
- Department of Medicine, University of Alberta Faculty of Medicine, Edmonton, Alberta, Canada
| | - Konstantin Koro
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Carla S Coffin
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Wenjie Wang
- Division of Nephrology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Naheed Syeda
- Division of Nephrology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Bonnie Meatherall
- Division of Infectious Diseases, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Dionne-Odom J, Cozzi GD, Franco RA, Njei B, Tita AT. Treatment and prevention of viral hepatitis in pregnancy. Am J Obstet Gynecol 2022; 226:335-346. [PMID: 34516961 PMCID: PMC8907340 DOI: 10.1016/j.ajog.2021.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 02/06/2023]
Abstract
Viral hepatitis in pregnancy may be caused by many types of viruses that cause systemic infection or target hepatocytes in their pathogenesis. Because viral hepatitis during pregnancy may represent acute or chronic infection or the reactivation of a prior infection, a high clinical suspicion, medical history review, and awareness of risk factors for the acquisition of infection are important management principles. The route of infection varies widely and ranges from fecal-oral transmission for the hepatitis A and E viruses to vertical transmission for hepatitis B, blood-borne transmission for hepatitis C, and sexual transmission for the herpes simplex virus. For this reason, the exposure details about travel, food preferences, drug use, and sexual contacts are important to elicit. Although routine prenatal screening is recommended for chronic viral hepatitis caused by hepatitis B and C, most other causes of viral hepatitis in pregnancy are detected in the setting of compatible signs and symptoms (fatigue, abdominal discomfort, jaundice, scleral icterus) or incidentally noted transaminitis on routine labs. Serologic testing is helpful for diagnosis with molecular testing as indicated to guide the management of hepatitis B and C. Preventive vaccines for hepatitis A and B with established safety of use in pregnancy are recommended for women who are at risk of acquisition. Postexposure prophylaxis for hepatitis A is a single dose of immunoglobulin and vaccination can be used if immunoglobulin G is not available. Antiviral therapy with tenofovir disoproxil fumarate is recommended as prophylaxis in pregnant women with active hepatitis B and an elevated viral load (>200,000 IU/mL) during the third trimester to prevent vertical transmission. The neonate exposed to hepatitis B at birth should receive immunoglobulin G and a monovalent birth dose vaccine within 12 hours, followed by completion of the 3-dosage vaccine series. The prevalence of hepatitis C in women of reproductive age has increased in the United States, and the role of antiviral therapy during pregnancy is of great interest. Cesarean delivery is not currently recommended for the sole purpose of reducing vertical transmission risk in pregnant women with viral hepatitis. Breastfeeding is recommended in women with hepatitis A, B, and C. New and promising prevention and treatment options for hepatitis B and C are under investigation. Investigators and regulatory authorities should ensure that these clinical trials for promising antivirals and vaccines are designed to include pregnant and lactating women.
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Affiliation(s)
- Jodie Dionne-Odom
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL; Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL.
| | - Gabriella D. Cozzi
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ricardo A. Franco
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Basile Njei
- Yale Center for Clinical Investigation, Yale School of Medicine, New Haven, Connecticut
| | - Alan T.N. Tita
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Alabama at Birmingham, Birmingham, Alabama,Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
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Hansen JD, Perri RE, Riess ML. Liver and Biliary Disease of Pregnancy and Anesthetic Implications: A Review. Anesth Analg 2021; 133:80-92. [PMID: 33687174 DOI: 10.1213/ane.0000000000005433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Liver and biliary disease complicates pregnancy in varying degrees of severity to the mother and fetus, and anesthesiologists may be asked to assist in caring for these patients before, during, and after birth of the fetus. Therefore, it is important to be familiar with how different liver diseases impact the pregnancy state. In addition, knowing symptoms, signs, and laboratory markers in the context of a pregnant patient will lead to faster diagnosis and treatment of such patients. This review article discusses changes in physiology of parturients, patients with liver disease, and parturients with liver disease. Next, general treatment of parturients with acute and chronic liver dysfunction is presented. The article progresses to specific liver diseases with treatments as they relate to pregnancy. And finally, important aspects to consider when anesthetizing parturients with liver disease are discussed.
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Affiliation(s)
- Jennette D Hansen
- From the Department of Anesthesiology, North Kansas City Hospital, North Kansas City, Missouri
| | - Roman E Perri
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthias L Riess
- From the Department of Anesthesiology, North Kansas City Hospital, North Kansas City, Missouri.,Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
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Disseminated herpes simplex virus 2 as a complication of pregnancy. IDCases 2021; 24:e01107. [PMID: 33889496 PMCID: PMC8047449 DOI: 10.1016/j.idcr.2021.e01107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022] Open
Abstract
Disseminated herpes simplex virus 2 (HSV-2) infection, is a rare but devastating infection in pregnancy women. We present the case of a 30-year-old gravida 3, para 2-0-0-2, at 26 weeks 2 days gestation who presented with eleven days of vague and indolent symptoms before a diagnosis of disseminated HSV-2 infection with associated hepatitis was made. While the patient clinically improved with empiric acyclovir treatment, possibility of significant harm to the fetus remained, and the patient request elective termination. The authors review the epidemiology, diagnosis, treatment, and prognosis of disseminated HSV-2 infection in pregnancy.
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Sarkar M, Brady CW, Fleckenstein J, Forde KA, Khungar V, Molleston JP, Afshar Y, Terrault NA. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:318-365. [PMID: 32946672 DOI: 10.1002/hep.31559] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Monika Sarkar
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Jean P Molleston
- Indiana University and Riley Hospital for Children, Indianapolis, IN
| | - Yalda Afshar
- University of California, Los Angeles, Los Angeles, CA
| | - Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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Abstract
BACKGROUND Herpes simplex virus (HSV) causes only 2-4% of all acute hepatitis but has high morbidity and mortality. Pregnancy is a risk factor for HSV hepatitis. We describe a case of gestational HSV hepatitis. CASE A 32-year old woman, gravida 2 para 1, presented at 38 2/7 weeks of gestation with back pain and fetal tachycardia. She became febrile after admission, had spontaneous rupture of membranes, and was delivered by cesarean for malpresentation. Postpartum, she became persistently febrile and developed transaminitis, symptomatic hypotension, and pancytopenia despite antibiotics. Imaging revealed acute liver injury, splenomegaly, pleural effusions, and cardiomyopathy. Serum polymerase chain reaction (PCR) screening identified HSV-1 infection. The patient recovered on acyclovir. There was no evidence of neonatal seroconversion. CONCLUSION Herpes simplex virus hepatitis causes significant morbidity, and pregnant women are susceptible to severe infections. Pregnant or peripartum women with acute febrile hepatitis require prompt evaluation for HSV with serum PCR screening.
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