P4838 - Complicated Course of Herpes Simplex Virus (HSV) Hepatitis in a Young Female With Systemic Lupus Erythematosus

Reid Gordon, BS¹, Taher Jamali, MD², Syed-Mohammed Jafri, MD^3
1Wayne State University School of Medicine, Oak Park, MI; ²Henry Ford Hospital, Detroit, MI; ³Henry Ford Health, Detroit, MI

Introduction: Herpes Simplex Virus (HSV) hepatitis is a viral-induced hepatitis that can rapidly progress into acute liver failure (ALF) and death if rapid diagnosis and prompt intervention are not pursued. We present an interesting case of HSV-2 related hepatitis in a young female with recurrent genital infections, fevers, chills and body aches.

Case Description/Methods: A 29-year-old female with a past medical history of hypertension, pulmonary cavitary lesions, and nephrotic range proteinuria presents with complaints of fevers, chills and body aches for over one month. Laboratory evaluation reveals pancytopenia, hematuria, nephrotic range proteinuria, antinuclear antibody positive to 1:1280 and positive SSA. The patient is diagnosed with systemic lupus erythematosus (SLE) and lupus nephritis and is started on hydroxychloroquine, mycophenolate, and steroids. She then develops acute encephalopathy and seizures, attributed to posterior reversible encephalopathy syndrome (PRES). PRES is confirmed by magnetic resonance imaging (MRI) and no cerebral edema is noted.



The patient develops persistent fevers and transaminitis, originally believed to be related to medication. Doppler ultrasound of the liver is unremarkable. Physical examination reveals mucocutaneous herpetic lesions and HSV-2 DNA by polymerase chain reaction (PCR) is detected, suggesting HSV hepatitis. At this time, the patient exhibits elevated levels of aspartate transaminase (AST) at 233 IU/L, alanine transaminase (ALT) at 312 IU/L, alkaline phosphatase (ALP) at 168 IU/L, and creatine at 1.89 mg/dL. Bilirubin levels and prothrombin time/international normalized ratio are within normal limits. Patient was treated with 2.5 mg/kg IV acyclovir daily for two days and is then discharged on 1g valacyclovir twice daily for three weeks. Following completion of course, the patient still presented with extensive genital ulcers and continued to test positive for HSV-2 DNA in blood, so she is prescribed 400 mg valacyclovir twice daily. Two months later, her AST, ALT, ALP, and creatinine values decrease to within normal limits and mucocutaneous lesions are absent.

Discussion: HSV hepatitis is a rare form of viral-induced hepatitis with nonspecific symptoms such as fever, encephalopathy, and elevated liver enzymes that particularly affects immunocompromised individuals. While the gold standard for HSV hepatitis is a liver biopsy, empiric antiviral treatment in cases of suspected HSV hepatitis based on serology may be warranted to minimize morbidity and mortality.


Disclosures:


Reid Gordon, BS¹, Taher Jamali, MD², Syed-Mohammed Jafri, MD³. P4838 - Complicated Course of Herpes Simplex Virus (HSV) Hepatitis in a Young Female With Systemic Lupus Erythematosus, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.