Rapid fulminant liver failure after anal exposure to genital herpes: a case report

Abstract

Fulminant hepatic failure from herpes simplex virus (HSV) in immunocompetent individuals has been reported but is quite rare. We present an unusual case of acute HSV infection transmitted anally causing fatal hepatitis in a young individual with no apparent immunosuppressive illness. A 44 year-old previously healthy female with a past history significant only for asthma and shingles presented with a five day history of diarrhea, anorexia, arthralgias, diffuse abdominal pain and high grade fever (105F). Three days prior to her becoming ill the patient had anal intercourse with her boyfriend who had active genital herpes. Her primary care physician started the patient on oral ciprofloxacin. Her symptoms worsened and she was admitted. Diagnostic work-up revealed WBC of 5.0 103/ul, ALT- 221 IU/L, AST-527 IU/L, total bilirubin of 2.3mg/dl, alkaline phosphatase (ALK) of 189-IU/L, Albumin of 2.5g/dl, INR of 1.7, negative serologies or titers for hepatitis A, B, C; CMV, HIV, syphilis and ANA. Microbiologic work-up was unremarkable. The patient began to deteriorate clinically and developed acute respiratory distress syndrome as well as abdominal ascites. Transjugular liver biopsy was performed which revealed subacute hepatocyte necrosis involving 15–20% of the submitted tissue with marked polymorphonuclear infection and inclusion bodies. The patient was transferred to our facility. On examination, the patient was tachypneic and was found to have a scattered discrete vesicular rash on her face/torso/extremities as well as a protuberant abdomen with percussion tenderness in the right upper quadrant. Labs revealed a total bilirubin of 8.8 (direct 8.7), AST- 296, ALT-430, ALK- 190, creatinine of 4.2mg/dl and an INR of 2.3. The liver biopsy was re-evaluated and immunostains for HSV I and II were positive. The patient was intubated and aggressive supportive care in the ICU was initiated including therapy with acyclovir. She developed multi-organ failure and expired after 2 weeks. Thus we present an unusual case of acute fulminant hepatic failure secondary to genital herpes infection after anal exposure. Hepatitis caused by HSV infection carries a very high mortality, which is unchanged with institution of acyclovir (except if it is started very early) and even worsened by liver transplantation, which is therefore contraindicated.