P4845 - Navigating Diagnostic Challenges: Herpes Simplex Virus as an Uncommon Cause of Acute Liver Failure in a Low-Risk Patient

John Paul Braun, BA¹, Rees Checketts, DO¹, Shalini Jain, MD^2
1Creighton University School of Medicine, Omaha, NE; ²CHI Health Creighton University Medical Center, Omaha, NE

Introduction: Acute liver failure (ALF) presents with jaundice, coagulopathy, and encephalopathy due to a sudden loss of liver function [1]. Herpes simplex virus (HSV) infection is a rare, yet serious cause. Its rarity and non-specific symptoms often lead to delayed diagnosis and treatment increasing the risk of death. We report a unique case of ALF caused by HSV in a patient without typical risk factors, diagnosed through liver biopsy.

Case Description/Methods: A 33-year-old female with a history of obesity was admitted to the ED with symptoms of jaundice, persistent weakness, fatigue, increased thirst with dark urine, and flank pain over the preceding few weeks. She denied fever, chills, nausea, vomiting, or diarrhea. Blood tests showed elevated liver enzymes, an elevated INR of 1.9, and direct bilirubin of 15.8 mg/dl.

The initial workup excluded acetaminophen toxicity, viral hepatitis A, B, and C, EBV, CMV, VZV, autoimmune hepatitis, Wilson disease, hemochromatosis and Alpha-1 antitrypsin deficiency. Initially, her HSV PCR testing was negative. Imaging studies demonstrated hepatosplenomegaly and evidence of hepatic inflammation. However, due to concerns about bleeding risk, an immediate liver biopsy was deferred.



As the patient's INR and liver enzymes worsened throughout the week, a transjugular liver biopsy was deemed necessary. The liver biopsy surprisingly confirmed an HSV infection. Treatment with acyclovir was initiated on day nine. Despite this she continued to decline. She was then transferred to a transplant center and successfully underwent liver transplantation on day 10 following initiation of acyclovir. Post-transplant pathology did not identify any clear etiology of ALF, and it was labeled cryptogenic.



Discussion: Despite advances in noninvasive diagnostic tools for liver conditions, liver biopsy remains an important diagnostic procedure [2]. The American Association for the Study of Liver Diseases recommends liver biopsy for cases of ALF where the etiology remains unclear after a comprehensive diagnostic workup [3]. This patient's scenario underscores the continued utility of liver biopsy in diagnosing complex cases of ALF.



Clinical evidence supports the efficacy of early acyclovir administration [4][5]. In instances of critical illness, it can play an important role in eradicating suspected viruses or preventing further decline. We hypothesize that this patient may have cleared her virus between the two biopsies, though that is uncertain as well.


Disclosures:


John Paul Braun, BA¹, Rees Checketts, DO¹, Shalini Jain, MD². P4845 - Navigating Diagnostic Challenges: Herpes Simplex Virus as an Uncommon Cause of Acute Liver Failure in a Low-Risk Patient, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.