2312 Using Serum Transaminase Ratios to Recognize Herpes Simplex Hepatitis

Abstract

INTRODUCTION: Herpes simplex virus (HSV) hepatitis is an uncommon cause of acute liver failure (ALF). HSV hepatitis accounts for less than 2% of all cases of viral ALF. The clinical presentation is non-specific including encephalopathy, leukopenia, and fever. Typical HSV skin manifestations are present in less than 50% of cases. Diagnosis is challenging due to the lack of timely and reliable serologic testing. Liver biopsy can help with diagnosis however is not always available. Reported mortality is 88% for untreated HSV hepatitis. Early treatment with acyclovir reduces mortality to 51%. Current guidelines recommend starting acyclovir if HSV hepatitis is suspected (1). CASE DESCRIPTION/METHODS: A 67 year-old female presented with a four day history of nausea, vomiting, diarrhea, and progressive weakness. On admission, she was hemodynamically stable with a fever of 102.8F. Physical exam revealed RUQ tenderness. No labial or genital lesions were present. Laboratory testing revealed WBC 2500 IU/L, platelets 108,000/mm3, AST 3038 IU/L, ALT 696 IU/L, ALP 181 IU/L, TB 0.2 mg/dL, and INR 1.5. Viral hepatitis serologies were negative. CT abdomen revealed a 4.9 × 3.7 × 3.5 cm enhancing lesion in the liver dome. Liver biopsy of lesion showed multifocal non-zonal massive necrosis consistent with HSV hepatitis. The patient was started on IV acyclovir at 7mg/kg/8hr on hospital day twelve for a total of fourteen days. The patient improved and liver enzymes normalized prior to discharge. DISCUSSION: A prior review of sixteen case reports described HSV hepatitis presenting with a hepatocellular liver injury pattern of AST significantly more elevated than ALT (2). This case presented similarly, with the AST:ALT ratio being nearly 5:1. Despite this pattern previously being recognized, it is not regularly described in review articles or practice guidelines. Early treatment with acyclovir lowers mortality of HSV hepatitis, yet there are no clear recommendations on when we should suspect HSV hepatitis. Clinicians should consider early empiric acyclovir for ALF when traditional viral hepatitis serologies are negative and give special consideration for hepatocellular liver injuries with significantly elevated AST:ALT ratios as this may represent a pattern for HSV hepatitis.