University of Texas Health Science Center at Houston Houston, TX, United States
Maneera Chopra, MD1, Preethi Reddy, MD2, Jamie Everett, MD2 1University of Texas Health Science Center at Houston, Houston, TX; 2University of Texas Medical School at Houston, Houston, TX
Introduction: Disseminated herpes simplex virus (HSV) is a rare cause of acute liver failure (ALF) in pregnant patients and may present insidiously. This condition leads to high morbidity and mortality and may progress to liver failure with features of portal hypertension. Starting acyclovir therapy empirically in suspected cases of ALF secondary to HSV should be considered and may impact outcome.
Case Description/Methods: A 40-year-old and 28 weeks pregnant female with no past medical history presented with upper respiratory symptoms, fevers, chills, premature rupture of membranes, anemia, and elevated transaminases. The patient previously had normal pelvic exams. She underwent Cesarean section on admission due to concerns for chorioamnionitis. She developed ALF with peak serum transaminases to 3600 with elevated International Normalized Ratio. She also had a ferritin > 9000, high triglycerides, and anemia of 6.8 gm/dL. Hepatology and Infectious disease teams were consulted. An abdominal ultrasound of the liver with doppler showed hepatomegaly with normal flow. An MRI showed cirrhotic liver morphology with perigastric and perisplenic varices. The patient’s ceruloplasmin, haptoglobin, and alpha-1 antitrypsin were elevated. Autoimmune workup including IgG, antinuclear antibody, and antimitochondrial antibody were negative. The patient was started empirically on broad spectrum antibiotics without improvement and acyclovir was added to the regimen. HSV-II blood polymerase chain reaction was positive, and the patient also underwent liver biopsy which showed patchy necrosis and widened hepatic fissures with immunostaining positive for HSV-I and HSV-II. The patient’s clinical status and transaminases improved to baseline after 6 weeks of acyclovir and she was subsequently discharged.
Discussion: Cases of disseminated HSV presenting as ALF have been reported in pregnant patients despite normal pap smears. However, this case appears to be unique as the patient did not have any history of HSV or primary lesions such as vesicles. The patient developed features of portal hypertension including varices and ascites despite lack of cirrhotic features on biopsy. The patient would likely have decompensated further if she had not been empirically started on acyclovir as ALF secondary to acute HSV hepatitis is time sensitive and carries high mortality. Our case illustrates consideration for starting acyclovir empirically in cases of ALF especially in immunocompromised patients or pregnant women if no other etiology is found.
Figure: Figure 1: A) Liver biopsy showing positive immunohistochemical staining for HSV 1 and 2 with necrotic hepatic tissue. B) Hematoxylin and eosin (H&E) stain showing patchy azonal confluent necrosis with an abrupt transition from unremarkable, viable hepatic parenchyma to necrosis. C) T2 weighted Magnetic Resonance Imaging (MRI) with liver protocol showing nodular hepatic surface, heterogeneous signal, and patchy enhancement (red arrow) which is seen in infiltrative diseases.
Disclosures: Maneera Chopra indicated no relevant financial relationships. Preethi Reddy indicated no relevant financial relationships. Jamie Everett indicated no relevant financial relationships.
Maneera Chopra, MD1, Preethi Reddy, MD2, Jamie Everett, MD2. P2877 - Disseminated Herpes Simplex Virus Presenting Insidiously as Acute Hepatitis in Pregnancy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.