Fatal Herpes Simplex Hepatitis in an Immunocompetent Patient: A Case Report and Review of the Literature

1Staten Island University Hospital, Staten Island, NY
2Staten Island University Hospital, Staten Island, NY
3Staten Island University Hospital, Staten Island, NY

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 185

Case Presentation:

A 78‐year‐old man with hypertension, diabetes mellitus, and hyperlipidemia presented to the ER for a 3‐day history of generalized malaise and fever. He denied headache, cough, abdominal pain, nausea, or vomiting. Medications included acetaminophen, hydrochlorothiazide, lisinopril, glyburide, metformin, and simvastatin. Vital signs were significant for a temperature of 102°F. On physical exam, he was alert and oriented to person, place, and time and had crackles over the left lower lung field. No skin lesions were noted, and the rest of the exam was normal. Labs revealed normal BMP, CBC, PT, PTT, INR, and urinalysis on admission, whereas AST = 412 U/L, ALT = 251 U/L, and total bilirubin = 1.7 mg/dL. On chest X‐ray a possible left lower lobe infiltrate was noted. The patient was admitted with the impression of community‐acquired pneumonia and was started on intravenous antibiotics. Acetaminophen and simvastatin were held. Over the next 24 hours, the patient became confused and had persistent fevers. His white blood cell count decreased from 4.3 to 0.8 K, platelets dropped from 127 to 43 K/mm3, and AST and ALT increased to 9548 and 3600 U/L, respectively. He also developed hypotension, a coagulopathy with an INR of 15, and acute respiratory distress requiring intubation and transfer to the ICU on broad‐spectrum intravenous antibiotics and vasopressors. Despite aggressive measures, the patient developed multisystem organ failure and died. Hepatitis profile and blood and urine cultures were negative. Autopsy revealed type 2 herpes simplex hepatitis, whereas lung sections were negative for bronchopneumonia.

Discussion:

Herpes simplex infection typically manifests as a benign self‐limiting disease with mucocutaneous lesions and a mild viral syndrome. Patients at high risk for disseminated herpes simplex are usually pregnant women, neonates, or the immunosuppressed. Immunocompetent patients are rarely affected, and the diagnosis is often missed in these patients because of lack of specific signs and symptoms. A literature review revealed only 8 case reports of disseminated herpes simplex occurring in the immunocompetent host. The triad of fever, elevated transaminases, and leukopenia is suggestive of herpes hepatitis. HSV DNA by PCR, when available, has emerged as a rapid and sensitive diagnostic tool for verification of disseminated HSV disease and should be utilized when possible. However, the definitive diagnosis is made by liver biopsy. Given the high mortality in these cases, rapid initiation of empiric antiviral treatment is imperative.

Conclusions:

Herpes simplex hepatitis in an immunocompetent patient is very rare. Clinicians should have an awareness of this unusual entity given that early diagnosis and treatment can significantly alter survival.

Author Disclosure:

M. Patel, none; T. Abdallah, none; A. Gottesman, none.

To cite this abstract:

Patel M, Abdallah T, Gottesman A. Fatal Herpes Simplex Hepatitis in an Immunocompetent Patient: A Case Report and Review of the Literature. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 185. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/fatal-herpes-simplex-hepatitis-in-an-immunocompetent-patient-a-case-report-and-review-of-the-literature/. Accessed June 19, 2019.

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