Scott R. Douglas, MD, Jennifer Miller, MD, Zachary Henry, MD, MS
University of Virginia, Charlottesville, VA
Introduction: Herpes simplex virus (HSV) is a highly prevalent virus but only rarely results in fulminant hepatitis. The prevalence of HSV1 and HSV2 are reportedly 53.9% and 15.7% in the general United States population. However, despite the high prevalence it is only responsible for 1% of all acute liver failure. Immunocompetent individuals represent only 24% of these cases. We present three cases of HSV hepatitis in the presumed immunocompetent host.
Case Description/Methods: Case 1: A 70 y.o male with type II diabetes presented with high fevers. His transaminases peaked at AST 973 and ALT 1183. His INR and T Bili both peaked at 1.4. Due to the anicteric nature of his hepatitis, he was started on empiric acyclovir. He developed nonspecific encephalopathy, later attributed to hospital acquired delirium. Cerebrospinal fluid was negative for HSV. His HSV serum PCR was positive for HSV1 on day 8. He later developed painful oropharyngeal ulcers. His liver enzymes and mental status would normalize.
Case 2: A 19 y.o female with osteogenesis imperfecta and lupus (treatment naive) presented after a sexual assault with fevers. She developed right upper quadrant pain and a pustular rash on upper extremities. Her liver enzymes peaked at AST 2,480 and ALT 824 on day five of admission. Her INR and total bilirubin peaked at 2.8 and 1.5, respectively. Due to the anicteric nature of her hepatitis, she was empirically treated with acyclovir. Her serum HSV PCR returned positive for HSV2 on day twenty. Liver enzymes improved and she was discharged on PO valganciclovir.
Case 3: A 21 y.o female with history of chlamydial infection presented with a diffuse urticarial rash, fever and right upper quadrant pain. Her AST was 2389 and ALT 1896. Total bilirubin peaked at 1.3. Due to the anicteric nature of her hepatitis, she was empirically treated with acyclovir. PCR of an oral lesion was positive for HSV2 and her serum PCR was positive for HSV2. She recovered completely.
Discussion: Despite low occurrence rates, our cases demonstrate HSV hepatitis must be kept in the differential diagnosis of hepatitis in the immunocompetent host. Progression to acute liver failure (ALF) occurs in 74% of HSV hepatitis cases. ALF from HSV has a mortality rate of 90%. Therefore, high clinical suspicion must be maintained for favorable outcomes. Fortunately, our patients had resolution of their HSV hepatitis due to early recognition of anicteric hepatitis and treatment with empiric acyclovir.
Citation: Scott R. Douglas, MD, Jennifer Miller, MD, Zachary Henry, MD, MS. P0741 - HERPES SIMPLEX VIRUS HEPATITIS IN IMMUNOCOMPETENT HOSTS - A CASE SERIES DEMONSTRATING THE IMPORTANCE OF EARLY RECOGNITION AND EMPIRIC ANTIVIRAL THERAPY. Program No. P0741. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.