Herpes simplex virus hepatitis causing fulminant liver failure in a non-pregnant woman

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Conference Proceeding

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Am J Gastroenterol


Introduction: HSV hepatitis is a rare cause of acute liver failure resulting in high morbidity and mortality with 74% progressing to death or liver transplant. Diagnosis is often delayed due to nonspecific symptoms, with the presence of characteristic rash in less than 50%. We present the case of a previously healthy non-pregnant woman who presented with acute liver failure from HSV-2 infection requiring transplant. Case Description/Methods: A 37-year-old woman presented to the ER with a 2-week history of fever, chills, and fatigue. She had been using acetaminophen 1 g q 3-4 hours for 1 week and reported longstanding alcohol use. She had normal mentation and no visible skin rashes. Labs showed ALT 3000, AST 5070, bilirubin 3.0, ALP 962. INR was 1.38 with an undetectable acetaminophen level. Tests for SARS-CoV-2, influenza, and Streptococcus were negative. She was started on N-acetylcysteine and transferred for consideration of liver transplant due to presumed acetaminophen-induced liver toxicity. On arrival the patient was alert but confused and unable to give an accurate history. Exam showed no oral, body or vaginal rash. Viral serologies showed CMVPCR -, EBV detected < 500, HIVRNA -, HCVRNA and HBVDNA -, HSV1 ND, HSV2 detected. Acyclovir (IV 10 mg/kg, 3 times/day) was started. Over 24 hours, mental status continued to decline requiring intubation. Liver biopsy revealed 70% submassive non-zonal necrosis with mixed portal inflammation and diffuse microvesicular steatosis, with no viral cytopathic effect. She underwent an uncomplicated orthotopic liver transplantation the next day. Explanted liver pathology showed submassive hepatic necrosis with staining positive for HSV. She continued on iv acyclovir and was discharged home. HSV remains detectable 25 days following transplant. At follow up patient described a diffuse macular rash which was present and resolved for 36 hours prior to hospital presentation. Discussion: This case illustrates the insidious onset and rapid clinical deterioration that can occur with HSV hepatitis. Given a high mortality rate, empiric initiation of IV acyclovir should be considered in patients with quantifiable HSV viremia and a viral prodrome. Our patient's non-characteristic rash resolved prior to evaluation, masking clinical suspicion for HSV hepatitis in the setting of acetaminophen and alcohol use. Patients may have clinical and histologic features suggesting drug-induced liver injury; thus, a broad differential diagnosis is key for early recognition and effective treatment.

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