Herpes Simplex Hepatitis in a Young, Healthy Female

Herpes simplex hepatitis (HSV) is a rarely encountered infectious hepatitis and is more commonly seen in immunocompromised and pregnant females. Prompt recognition and treatment is needed to prevent morbidity and mortality. Delays in treatment can be fatal. A 25 year old female presented to the ER with fevers and myalgias for the 3 days. A CBC and BMP were unremarkable. A pregnancy, monospot and rapid flu tests were negative. An abdomen CT reported hepatomegaly with steatosis. The patient was discharged from the ER. The patient returned 2 days later with worsening fevers. Repeat labs noted leukopenia with thrombocytopenia, and severe transaminitis (AST 1,810 U/L, ALT 1,224 U/L) with a normal total bilirubin, alkaline phosphatase, and lipase levels. INR was elevated. A toxicology screen, salicylate and acetaminophen levels were negative. Hepatitis A, B, and C tests were negative. Empiric IV acyclovir was started for suspected viral etiology. A RUQ ultrasound found possible cholecystitis, no gallstones, 0.9 cm common bile duct diameter, patency of the portal veins with normal venous waveforms, and a normal appearing liver. An MRCP followed and confirmed the findings on the ultrasound report. EBV testing revealed likely past exposure, but no acute infection. ANA screen was negative. HIV and Varicella PCR tests were negative. HSV I and II IgG antibodies were elevated. A PCR study was positive for HSV I. Gynecology noted ulcerated vaginal lesions consistent with HSV infection. Later, a liver biopsy was performed. The pathology review by Mayo Medical Laboratories reports centrilobular necrosis with areas of extension to portal tracts with every necrotic focus impinging on a central vein. Unlike typical drug-related zone 3 necrosis, the necroinflammatory process does not encircle central veins. The abnormal foci have apparent suppurative necrosis and loose collections of histiocytes suggestive of granuloma with the overall picture suggestive for an infectious process. No viral cytopathic inclusions were readily identified. Unfortunately no viral inclusions were seen on biopsy, but the patient had received 5 days of IV acyclovir prior. Based on the pathology report along with the positive PCR test and active vaginal lesions, the patient contracted HSV hepatitis. This case demonstrates a case of HSV hepatitis in an otherwise young, healthy female and the importance of early recognition and treatment with IV acyclovir.Figure: Centrilobular necrosis with central vein on the right and portal tract on the left.Figure: Centrilobular necrosis with inflammation and plasma cells.