Patient 2 was a year-old Caucasian female with asthma no corticosteroids who presented with abdominal pain, fever, and painful swallowing over 20 days before the onset of ALF. Acyclovir was not administered. The patient died 2 days after admission. Autopsy revealed HSV esophagitis and hepatitis with coagulative necrosis. Patient 3 is a year-old Caucasian male with asthma no corticosteroids who developed fever and a vesicular rash in the 8 days prior to ALF.
Liver biopsy showed hepatic necrosis and intranuclear inclusions consistent with HSV infection. Initial immunosuppression included tacrolimus, mycophenolate mofetil MMF , and 3 days of corticosteroids. MMF was discontinued, and IV acyclovir was resumed for 10 days. Post-LT complications included biliary leak and stricture, pneumonia, renal failure, and Aspergillus fumigatus osteomyelitis. After 2 years, the patient has not developed recurrence of HSV on maintenance valacyclovir mg once a day.
Herpes simplex virus polymerase chain reaction levels during antiviral therapy prior to liver transplantation patients 3 and 4. Patient 4 was a healthy year-old Caucasian female who presented with a vesicular eruption and fever 10 days prior to ALF. Liver biopsy revealed HSV hepatitis. Initial immunosuppression included tacrolimus, MMF, and corticosteroids. Prednisone and MMF were discontinued. Postoperative complications included Candida fungemia, Staphylococcus aureus and Enterococcus faecium bacteremia, biliary stricture, and prolonged ventilation.
While on maintenance valacyclovir, the patient developed an acyclovir-resistant HSV rash negative serum PCR on day Foscarnet was administered, but the patient expired on day with no obvious HSV disease or viremia.
Autopsy was declined by the family. Herpes simplex virus polymerase chain reaction levels during antiviral therapy after liver transplantation patient 4. We focused on the utility of screening blood samples for evidence of occult HSV infection with a highly sensitive qualitative PCR assay. While hepatic recurrence of HSV after LT was not seen in either, the hospital courses were complicated by extrahepatic HSV infection and numerous complications, despite a significant reduction in HSV DNA immediately after hepatectomy and eventual clearance of viremia.
While the data are limited, these findings suggest that a decline in quantitative HSV DNA may not correlate with a reduction in posttransplant extrahepatic HSV or other morbidity. A positive serology without viremia would be highly unlikely to represent actual infection in the vascularized organs where high-titer viremia is universal. In support of this, a review of available liver tissue from these 7 subjects failed to demonstrate evidence of intranuclear inclusions.
In contrast, 2 of the 4 patients with known HSV infection had negative anti-HSV IgM levels, which reflected either the inaccuracy of serological testing or the fact that the patients were too ill or too early in the course of infection to manufacture IgM. These data highlight concerns regarding the diagnostic capability of serological testing for HSV and emphasize the importance of PCR as the definitive confirmatory test.
Merely removing the infected liver with transplantation dramatically reduced the HSV viral load, and this likely reflected the fact that the liver, being a highly vascularized organ, was a significant reservoir for HSV. The viral load of one of the patients did not become undetectable until 3 months after LT, while the other cleared more quickly. While our data are limited to these patients, they provide the first insight into the viral kinetics and associated outcomes of HSV ALF. The outcomes of the 2 transplanted patients in this study do not settle the controversy of whether LT for HSV should be performed in adults.
Other etiologies of fulminant liver failure, such as ischemic hepatopathy secondary to HSV encephalitis, were considered, but this differential was low given that the patient had no hemodynamic instability and had marked improvement in liver function with ACV therapy. Due to the rapid improvement with ACV treatment and the high risk of a liver biopsy due to substantial coagulopathy, a liver biopsy was not performed. Mortality and hospital stay decreases with early treatment with ACV.
We suspected ACV resistance after 10 days of treatment without improvement of mentation. This case emphasizes the importance of considering additional treatments for HSV encephalopathy in patients who fail to respond to initial therapy.
ACV is classified as a category B drug in pregnancy with no difference in birth defects when compared to the general population. HSV infections with resistance to ACV are mainly reported in immunocompromised patients, with the prevalence varying from 3.
In conclusion, our case illustrates an unusual presentation of HSV hepatitis. Diagnosis requires a high index of clinical suspicion. Early initiation of ACV is crucial for treatment. Duration of anti-viral treatment remains unclear, but continuation of therapy until resolution of symptoms, improvement in liver function tests, and negative serum PCR is advisable.
Our report demonstrates the need to add a second antiviral, in this case foscarnet, in an immunocompetent patient with a resistant infection. Author contributions: All authors wrote and edited the manuscript. Chaudhary is the article guarantor. National Center for Biotechnology Information , U. Published online Feb Author information Article notes Copyright and License information Disclaimer. Corresponding author.
Received Jul 19; Accepted Nov This is an open-access article. This article has been cited by other articles in PMC. Introduction Acute liver failure ALF is an uncommon outcome of herpes simplex virus HSV infection, which was first described in adults in Case Report A year-old immunocompetent Hispanic female, with a history of total laparoscopic hysterectomy and uterosacral suspension 5 months prior to presentation, presented with a 4-day history of worsening hypogastric abdominal pain.
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When it comes to treating the skin, plenty of people say they have expertise. Only a board-certified dermatologist has these credentials. Most people get HSV-1 herpes simplex type 1 as an infant or child. You are here Home Archive Volume , Issue Fulminant hepatic failure secondary to acyclovir-resistant herpes simplex virus. Email alerts. Article Text. Article menu. Fulminant hepatic failure secondary to acyclovir-resistant herpes simplex virus. Summary Liver failure is a frequent and serious complication that causes morbidity and mortality in haematopoietic stem cell transplantation HCT recipients.
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