P1363 - A Case of Herpes Simplex Virus Hepatitis in Patient With SLE on Belimumab

Averie Dickinson, MD, MBA¹, James Helzberg, MD¹, Berline Francis, MD¹, Ashley Jowell, MD², Lindsay Y. King, MD¹, Kristen Dicks, MD, MPH¹, Kara Wegermann, MD^1
1Duke University Health System, Durham, NC; ²Duke University Medical Center, Durham, NC

Introduction: Prompt clinical suspicion and early initiation of acyclovir for HSV hepatitis in patients presenting with nonspecific symptoms and acute liver injury are crucial to reducing mortality.

Case Description/Methods: A 54 year old woman with systemic lupus erythematosus (SLE) with secondary antiphospholipid syndrome on hydroxychloroquine and belimumab presented with dyspnea, vomiting, diarrhea, and fever to 102°F after recent treatment with cefdinir and steroids for presumed urinary tract infection and SLE flare.

On admission, she was hypoxic (94% on 60% FiO2) and afebrile. Exam showed an acutely ill appearing woman with increased work of breathing, decreased breath sounds, and a non-tender abdomen without hepatosplenomegaly. Labs indicated acute liver injury with aspartate aminotransferase (AST) 2768, alanine aminotransferase (ALT) 1457, Alkaline Phosphatase (ALP) 295, Total bilirubin (Tbili) 1.7, INR 1.9, and pancytopenia. Hepatitis B and C PCR was negative. She was started on empiric acyclovir for suspected HSV hepatitis.

Over the next 24 hours, her liver tests worsened (AST 4811, ALT 2375, ALP 358, Tbili 3.2, INR 2.2), she developed progressive hypoxic respiratory failure, necessitating ICU transfer. Parainfluenza PCR returned positive. She was found to have positive serum HSV 2 PCR with high viral load ( >1.0 E+08). Liver biopsy showed massive necrosis (80%) and multinucleated giant cells, with IHC stain confirming HSV hepatitis diagnosis. Her liver injury and respiratory failure improved and she was transitioned to valacyclovir, for indefinite therapy. She reported significant improvement at her one-month follow-up hepatology visit.

Discussion: Although rare, HSV hepatitis carries a high mortality rate of up to 60%, compared to 19-36% for other causes of severe acute hepatitis. Clinical presentations are often non-specific, resembling flu-like symptoms such as fever, nausea, vomiting in immunocompromised or competent individuals. Both SLE and immunosuppression are established risk factors, but to our knowledge this is the first reported case in a patient on belimumab, a B-cell activator inhibitor. While HSV DNA PCR, and CT scans are useful, a liver biopsy showing pathognomonic confluent necrosis, atypical giant cells, and positive IHC staining is the gold standard. Diagnostic delay is common in cases of HSV hepatitis, with only 30% of patients receiving early antiviral treatment. Early acyclovir treatment, initiated before waiting for the definitive diagnosis, is crucial to reduce mortality.



Disclosures:


Averie Dickinson, MD, MBA¹, James Helzberg, MD¹, Berline Francis, MD¹, Ashley Jowell, MD², Lindsay Y. King, MD¹, Kristen Dicks, MD, MPH¹, Kara Wegermann, MD¹. P1363 - A Case of Herpes Simplex Virus Hepatitis in Patient With SLE on Belimumab, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.