S2636 A Unique Presentation of Liver Microabscesses, Herpes Simplex Virus Hepatitis

Abstract

INTRODUCTION: Herpes Simplex Virus (HSV) hepatitis is an uncommon but known cause of acute to fulminant hepatic failure associated with a high mortality rate if unrecognized and untreated. HSV hepatitis has a wide variety of presentations including necrosis and abscess formation, which are important to identify to prevent treatment delay. We present a unique case of hepatic microabscesses in an immunosuppressed patient who developed acute hepatitis secondary to herpes simplex virus (HSV) infection. CASE DESCRIPTION/METHODS: A 63 year old female with history of myelodysplastic syndrome/myeloproliferative neoplasm overlap syndrome 124 days post allogeneic hematopoietic cell transplantation presented with confusion, abdominal pain and perianal blisters. Initial work up revealed AST 216, ALT 205, alkaline phosphatase 98, total bilirubin 0.7 and non-reactive hepatitis viral panel. CT revealed numerous indeterminate hepatic hypodensities. CSF analysis was positive for HSV-2. Rectal blister swab and blood were positive for HSV-1 and HSV-2 DNA. Liver biopsy demonstrated areas of confluent necrosis; immunohistochemical stain for HSV-1 and HSV-2 revealed strong nuclear positivity. She was started on IV acyclovir and liver enzymes normalized. She was discharged on oral acyclovir. DISCUSSION: HSV is a rare cause of acute liver failure, accounting for 1% of total cases and 2% of viral hepatitis cases. Immunocompromised individuals and pregnant women are at increased risk for HSV hepatitis. One retrospective review found initial presenting symptoms were fever (98%), coagulopathy (84%), and encephalopathy (80%); herpetic skin lesions are present in less than 50% of cases. Quantitative HSV serum PCR is a sensitive and specific tool for detection of disseminated disease; however, tissue diagnosis with liver biopsy is the gold standard. Untreated patients develop fulminant hepatic failure, with most cases diagnosed at autopsy. Therapy with IV acyclovir has been shown to reduce mortality; therefore, empiric treatment should not be delayed when there is clinical suspicion. This case is unique with regards to the presence of hepatic microabscesses, which has been described in only two other cases of HSV hepatitis. Well-established etiologies of hepatic microabscesses include pyogenic liver abscess and in orthotopic liver transplant patients, CMV hepatitis and mini microabscess syndrome. Although exceedingly rare, HSV hepatitis should be considered in patients with hepatic microabscesses and acute hepatitis.Figure 1.: CT scan demonstrating liver microabscesses.Figure 2.: Liver core needle biopsy at high power field.Figure 3.: Liver biopsy with positive HSV 1 and 2 immunohistochemical stain.