2320 A Case Report of Herpes Simplex Virus Hepatitis Presenting as Fever of Unknown Origin

Abstract

INTRODUCTION: Herpes simplex virus (HSV) hepatitis accounts for only 2% of all viral hepatitis. It often presents in patients who are immunocompromised and pregnant women. Besides cutaneous findings which present in less than half of these patients, HSV hepatitis often lacks specific clinical findings leading to missed diagnosis and rapid progression to fulminant liver failure and multiorgan collapse. We report a case of a 58-year-old immunocompetent female who presented with fever of unknown (FUO) origin who developed transaminitis with pancytopenia and was diagnosed with HSV hepatitis by liver biopsy. CASE DESCRIPTION/METHODS: A 58-year-old female with past medical history of hypertension, hyperlipidemia, and cholelithiasis status post cholecystectomy presented with high grade fever and worsening abdominal pain for over a week. Physical examination revealed marked right upper quadrant tenderness, but no mucocutaneous lesions including genitalia. Initial laboratory findings showed transaminitis with ALT 139 (0-55 IU/L) and AST 172 (5-34 IU/L). Ultrasound of liver and MRCP showed mild hepatomegaly with hepatic steatosis without cirrhosis and biliary ductal dilatation. She developed pancytopenia and abrupt elevation in both ALT and AST to 822 IU/L and 1558 IU/L, respectively. She never developed coagulopathy or hepatic encephalopathy. Hepatitis A, B, C serologies were negative, ANA 1:320, anti-SMA 1:80, HSV2 IgM positive > 1:320 and HSV2 qualitative PCR was positive in serum. Acyclovir was initiated on day 6 of hospitalization with gradual improvement of fever and transaminitis (Figure 1). A liver biopsy was performed which showed hepatic necrosis with rare nuclei positive for HSV immunostaining (Figure 2). DISCUSSION: HSV hepatitis often presents as fulminant liver disease, with a mortality rate greater than 80%. Clinical features often include fever, anorexia with nausea and vomiting, abdominal pain, leukopenia, and coagulopathy. Our patient was originally diagnosed with FUO, defined as temperature higher than 38.3ºC on several occasions, duration of fever for at least three weeks, or uncertain diagnosis after one week of study in the hospital. In this case, we were able to diagnose and treat the patient early into her HSV hepatitis course, preventing acute liver failure and other complications. For this reason, we believe it is important test early for HSV in immunocompetent patients with FUO, mild to moderate transaminitis and pancytopenia to decrease morbidity and mortality.