Herpes Simplex Virus-2 Hepatitis: A Case Report and Review of the Literature

Sepsis and multi-organ failure due to genital herpes in a healthy person

Herpes simplex virus type 2 (HSV-2) is highly prevalent in several regions of the world and is the main pathogen causing genital herpes, which is transmitted almost exclusively through sexual contact. Systemically disseminated infections caused by HSV-2 are rare and most often seen in newborns, pregnant women, or immunocompromised populations. The virus can invade multiple organs and cause damage. In this paper, we present an extremely rare case of an immunocompetent 36-year-old male who came to our hospital with a high fever with abdominal pain and died of sepsis and multiple organ dysfunction syndrome within a short period. After the exclusion of common pathogens such as bacterial and fungal infections during hospitalization, metagenomic next generation sequencing of the patient's peripheral blood and ascites gave us the answer, and very high nucleic acid sequence counts of HSV-2 were detected in both his peripheral blood and ascites, confirming HSV-2 as the causative virus. In addition, this paper provides a brief review of the relevant literature.

Etiology of viral induced acute liver failure and defensins as potential therapeutic agents in ALF treatment

Acute liver failure (ALF) is a rare and severe disease, which, despite continuous advances in medicine, is still characterized by high mortality (65-85%). Very often, a liver transplant is the only effective treatment for ALF. Despite the implementation of prophylactic vaccinations in the world, the viral background of ALF is still a problem and leads to many deaths. Depending on the cause of ALF, it is sometimes possible to reverse this condition with appropriate therapies, which is why the search for effective antiviral agents seems to be a very desirable direction of research. Defensins, which are our natural antimicrobial peptides, have a very high potential to be used as therapeutic agents for infectious liver diseases. Previous studies on the expression of human defensins have shown that increased expression of human α and β-defensins in HCV and HBV infections is associated with a better response to treatment. Unfortunately, conducting clinical trials for ALF is very difficult due to the severity of the disease and the low incidence, therefore animal models are important for the development of new therapeutic strategies. One of the best animal models that has real reference to research on acute liver failure (ALF) is rabbit hemorrhagic disease in rabbits caused by the Lagovirus europaeus virus. So far, there have been no studies on the potential of defensins in rabbits infected with Lagovirus europaeus virus.

Fulminating herpes simplex hepatitis

Herpes simplex virus (HSV) is a rare cause of acute hepatitis in patients with chronic immunosuppression, including Crohn's disease. HSV hepatitis has the propensity to cause acute liver failure and death. The presenting signs and symptoms can be nonspecific, thereby causing the diagnosis to go overlooked with inadequate management, leading to a high mortality rate. We report a case of a 31-year-old male on chronic prednisone treatment for Crohn's disease who unexpectedly died. Subsequently, an autopsy showed HSV hepatitis as the cause of death. Thus, although a rare complication, HSV hepatitis should always be kept in mind as a fatal complication in patients with acute hepatitis and chronic immunosuppression.

Herpes simplex virus hepatitis in a renal transplant recipient seronegative pre-transplant

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.

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.

Acute liver failure due to herpes simplex virus: diagnostic clues and potential role of plasmapheresis: A case report

INTRODUCTION

Acute liver failure (ALF) is a life-threatening condition that remains challenging for physicians despite several advances in supportive care. Etiologies vary worldwide, with herpes simplex virus (HSV) hepatitis representing less than 1% of cases. Despite its low incidence, ALF is a lethal cause of acute necrotizing hepatitis and has a high mortality. Early antiviral treatment is beneficial for survival and decreased liver transplantation necessity. However, plasmapheresis, despite its theoretical potential benefit, is scarcely reported.

PATIENT CONCERNS

A 25-year-old woman with no known disease presented with painful pharynx ulcers, increased transaminases and impaired liver function.

DIAGNOSIS

ALF due to a disseminated HSV-2 primary infection was diagnosed with a positive polymerase chain reaction for HSV-2 in the biopsied liver tissue and blood.

INTERVENTIONS

Empiric antiviral treatment was initiated. After clinical deterioration, plasmapheresis was also initiated.

OUTCOMES

After 6 cycles of plasmapheresis and supportive care, the patient's condition improved without undergoing liver transplantation.

CONCLUSIONS

ALF is a life-threatening condition, and HSV as an etiology must be suspected based on background, clinical manifestation, and laboratory information. The potential role of plasmapheresis in HSV hepatitis should be considered.