C0567 - HSV Hepatitis Resulting in Acute Liver Failure and Liver Transplantation

James Mo, BA¹, Yasmine Hussein Agha, MD², Syed-Mohammed Jafri, MD^2
1Wayne State University School of Medicine, Detroit, MI; ²Henry Ford Health System, Detroit, MI

Introduction: Herpes simplex virus (HSV) is a rare cause of hepatitis that can result in acute liver failure (ALF) in 75% of affected patients and is associated with a high mortality rate (90%). We present a case of a 38-year-old female with ALF from HSV hepatitis resulting in orthotopic liver transplant (OLT).

Case Description/Methods: A 38-year-old female presents with abdominal pain, persistent fever, headache, and generalized malaise. Her mental status acutely decompensates, and she is intubated. Head CT reveals no acute process for cerebral edema. She is diagnosed with ALF, having elevated AST (5,070 IU/L), ALT (3,000 IU/L), TBIL (3.0 mg/dL), and INR (1.38). A complete blood count reveals low white blood cell count (1.7 K/uL) and platelet count (25 K/uL). HSV-2 is detected in the blood via polymerase chain reaction. Given her clinical presentation and rapid deterioration, she is urgently evaluated for liver transplantation and undergoes OLT shortly after being listed. A biopsy of her explant reveals submassive hepatic necrosis with positive immunostaining for HSV, predominantly in areas of necrosis, revealing underlying HSV viremia. Her post-transplant course is complicated by acute kidney injury requiring renal replacement therapy with improvement, bile leakage requiring Roux-en-Y hepaticojejunostomy, and neutropenia. The patient is treated with intravenous acyclovir and then transitioned to oral valacylovir, upon which she develops cytomegalovirus viremia and is started on valgancyclovir treatment. She clinically improves but did have recurrent labial lesions with HSV, similarly treated with valacylovir.

Discussion: HSV hepatitis is a rare cause of ALF. Its clinical presentation often includes fever, encephalopathy, coagulopathy, and acute renal failure. Leukopenia and thrombocytopenia are also commonly associated with HSV hepatitis. Mucocutaneous lesions are not present in more than half the patients. This makes diagnosis difficult without a thorough history, lab evaluation, and histopathology. Liver biopsy is the gold standard for diagnosis of HSV hepatitis with histology revealing focal or confluent areas of acidophilic-type necrosis with little inflammation. Treatment with acyclovir early in the course may result in a better prognosis and reduce the need for OLT. Once ALF is diagnosed, OLT is the definitive treatment. Because of its rapid and aggressive progression, consideration of HSV hepatitis in the differential diagnosis and timely treatment is critical.


Disclosures:


James Mo, BA¹, Yasmine Hussein Agha, MD², Syed-Mohammed Jafri, MD². C0567 - HSV Hepatitis Resulting in Acute Liver Failure and Liver Transplantation, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.