2285 HSV Hepatitis in an Immune-Competent Patient

Abstract

INTRODUCTION: A rare complication of herpes simplex virus (HSV) infection is hepatitis, especially in an immunocompetent host. It is important to recognize this diagnosis, as HSV hepatitis is potentially fatal if untreated due to the risk of acute liver failure. We present a case of HSV hepatitis in an immunocompetent patient with a benign clinical course. CASE DESCRIPTION/METHODS: A 58-year-old female with history of diabetes mellitus, breast cancer with distant history of chemotherapy, presented to the emergency department for one week history of right upper quadrant pain and fevers at home. On presentation she was febrile with a temperature of 39.3 degrees Celcius, blood pressure 118/72 mmHg, heart rate 100 bpm. Physical exam findings included tenderness to palpation of upper quadrants, flanks, and suprapubic area. Laboratory findings revealed alanine aminotransferase (ALT) 139 IU/L, aspartate aminotransferase (AST) 172 IU/L, and alkaline phosphatase 73 IU/L. She was negative for Hepatitis A, B, C, HIV, and influenza. A liver ultrasound showed an enlarged liver (19.5cm) with homogeneous parenchyma and increased echogenicity consistent with hepatic steatosis. The liver contour was smooth and there was no duct dilation. Her liver tests worsened with ALT and AST peaking at 822 and 1558, respectively. Due to persistent fevers, the patient was evaluated for HSV, and was found to be HSV-2 IgM positive (titer >1:320) and HSV-2 DNA was detected. The patient was started on intravenous acyclovir. A liver biopsy showed findings of periportal and pericentral necrosis, favoring infection. An immunohistochemical stain for HSV was positive. She completed 2 weeks of acyclovir, achieving improvement in liver tests to normal range. DISCUSSION: HSV is a common infection, but a rare cause of hepatitis, comprising < 2% of cases and < 1% of all causes of acute liver failure. HSV hepatitis is usually described in immunocompromised hosts, pregnant women, and neonates. Presentation is vague, but most commonly with fever, abdominal pain, and only 30% with typical oral or genital lesions. Diagnostic tools are serological testing for HSV and liver biopsy. Treatment with acyclovir is effective in preventing transplant or can be life saving in 51% if initiated promptly, and thus, a high index of suspicion is warranted in patients with appropriate risk factors or with an unclear etiology of severe transaminitis. Given our immunocompetent patient’s relatively benign course, this is a unique presentation of a potentially fatal disease.