acyclovir and Liver-Failure--Acute

Herpes simplex virus (HSV) hepatitis is an uncommon cause of liver failure, but may have a dramatic outcome. We herein present a case report of a liver graft infection by HSV-1 associated with liver failure and encephalitis. A complete hospital chart review of the case and a literature search were undertaken. Literature review suggests that herpes simplex acute liver failure is rare and associated with a poor prognosis, even with early treatment. Novel diagnostic and preventive approaches need to be instituted.

Topics: Acyclovir; Antiviral Agents; Encephalitis, Herpes Simplex; Fatal Outcome; Hepatitis, Viral, Human; Herpes Simplex; Herpesvirus 1, Human; Humans; Liver Failure, Acute; Liver Transplantation; Male; Middle Aged; Transplants

Acute liver failure is a life threatening disease mostly triggered by drug-induced or toxic liver damage or viral hepatitis. Herpes Simplex virus (HSV) hepatitis is rare and accounts for only 1% of all acute liver failures. The importance of HSV-induced acute liver failure is based on its extremely severe clinical course with lethality rates of almost 75%. HSV hepatitis is just one of several clinical manifestations of HSV sepsis leading more frequently to encephalitis, pneumonia and esophagitis. Local herpes infection or recurrence of dermal lesions (herpes labialis, herpes genitalis), however, is common and account for the high prevalence of HSV-1 or HSV-2 infection in adults. Another rare entity is visual dissemination, which mostly affects immunocompromised patients. Compromised cellular immunity is a major risk factor for HSV sepsis because of either primary infection or reactivation of occult chronic HSV infection. Delayed diagnosis without antiviral therapy significantly contributes to the unfavorable outcome. Typically, anicteric hepatitis is seen in patients with HSV hepatitis. Because of its low incidence, however, and the lack of dermal manifestations, HSV hepatitis is rarely considered in the context of acute liver failure. In addition, diagnostic tests might not always be available. Therefore, it is a generally accepted consensus to begin antiviral therapy pre-emptively with acyclovir in cases of acute liver failure of unknown origin, in which high urgency (HU) liver transplantation remains the only therapeutical option. Even in the case of early specific therapy, sepsis may prevail and the indication for HU transplantation must be evaluated carefully. The outcome after liver transplantation for HSV-induced liver failure with reported survival rates of more than 40% is good. Because of the risk of recurrence, lifelong prophylaxis with acyclovir is recommended.

Topics: Acyclovir; Antiviral Agents; Herpes Simplex; Humans; Liver Failure, Acute; Polymerase Chain Reaction; Sepsis

Topics: Abdominal Pain; Acyclovir; Adult; Antiviral Agents; Diagnosis, Differential; Fatal Outcome; Hepatitis; Herpesvirus 3, Human; Humans; Liver; Liver Failure, Acute; Male

Herpes simplex virus (HSV) is seen throughout the world and can be treated with acyclovir. We present a case of fulminant hepatic failure (FHF) as a result of disseminated HSV infection in a pregnant patient during the second trimester.. The medical records of a patient suffering from HSV-related fulminant hepatic failure were collected. A review of the literature was collected and reported.. A previously healthy female presented with fulminant hepatic failure at a local emergency room complaining of a 5-day history of fever, nausea, vomiting, and right side abdominal pain that radiated to the back. She was diagnosed with fulminant hepatic failure and progressed into a coma. The patient underwent orthotopic liver transplantation (OLT) prior to the diagnosis of HSV and then treated successfully with acyclovir.. Treatment of HSV fulminant hepatitis is dependent up on early suspicion and prompt intervention. In addition, antiviral therapy may need to be lifelong.

Topics: Acyclovir; Adult; Antiviral Agents; Female; Hepatocytes; Herpes Simplex; Herpesvirus 1, Human; Humans; Liver Failure, Acute; Postoperative Period

Continuous venovenous hemodiafiltration (CVVHDF) is one of the treatments of critically ill children presenting severe acute liver failure. This affliction might be induced by HSV infection requiring a treatment by acyclovir. Continuous kidney replacement therapy (CKRT) can alter its pharmacokinetics, according to its physicochemical properties and CVVHDF settings.. This case describes acyclovir pharmacokinetics during CKRT in a pediatric patient treated by acyclovir. The patient was treated with adapted exposure with the usual dosing, but lower dosing should be investigated with complementary studies.. ClinicalTrials.gov NCT02539407.

Topics: Acute Kidney Injury; Acyclovir; Child; Continuous Renal Replacement Therapy; Critical Illness; Dialysis Solutions; Female; Hemodiafiltration; Humans; Infant; Liver Failure, Acute

The incidence of acute liver failure from herpes simplex virus is rare.. A 71-year-old Japanese man was diagnosed with acute liver failure and was transferred to our hospital. Steroid therapy, plasma exchange, and hemodiafiltration were started for liver failure, and antimicrobial therapy was initiated for pneumonia. Staphylococcus epidermidis was detected in blood culture. Skin rash appeared; a positive anti-herpes simplex virus result led to the diagnosis of acute liver failure from herpes simplex virus. Hence, acyclovir was started. After blood tests improved, treatments for acute liver failure were discontinued. Antimicrobial therapy was continued; however, he died. In this case, persistent bacteremia and drug-induced liver damage due to acyclovir may have contributed to his death.. Acute liver failure can lead to complications and death. Thus, careful observation is crucial, even if the patient has shown some improvements.

Topics: Acyclovir; Aged; Antiviral Agents; Hepatitis, Viral, Human; Herpes Simplex; Humans; Liver Failure, Acute; Male

Herpes simplex virus 1 (HSV-1) is a frequently unrecognized, yet deadly cause of acute liver failure (ALF). We, therefore, analysed three cases of fatal HSV-1-induced ALF. All patients shared clinical (extremely elevated transaminases, LDH and AST/LDH ratio < 1) and virological characteristics (ratio of viral load in plasma versus throat swabs: 60-700-fold, lack of anti-HSV-1-IgG antibodies or low IgG-avidity during primary infection), which may help to identify patients at risk. Additionally, in vitro chemosusceptibility assays revealed high efficacy of the helicase-primase inhibitors (HPI), pritelivir and drug-candidate IM-250 compared to acyclovir (ACV) using HSV-1-isolates from two patients; hence, ACV/HPI-combinations might offer new therapeutic options for HSV-induced ALF.

Topics: Acyclovir; Antiviral Agents; DNA Helicases; DNA Primase; Herpesvirus 1, Human; Humans; Immunoglobulin G; Liver Failure, Acute; Pyridines

Acute liver failure (ALF) is a life-threatening condition that remains challenging for physicians despite several advances in supportive care. Etiologies vary worldwide, with herpes simplex virus (HSV) hepatitis representing less than 1% of cases. Despite its low incidence, ALF is a lethal cause of acute necrotizing hepatitis and has a high mortality. Early antiviral treatment is beneficial for survival and decreased liver transplantation necessity. However, plasmapheresis, despite its theoretical potential benefit, is scarcely reported.. A 25-year-old woman with no known disease presented with painful pharynx ulcers, increased transaminases and impaired liver function.. ALF due to a disseminated HSV-2 primary infection was diagnosed with a positive polymerase chain reaction for HSV-2 in the biopsied liver tissue and blood.. Empiric antiviral treatment was initiated. After clinical deterioration, plasmapheresis was also initiated.. After 6 cycles of plasmapheresis and supportive care, the patient's condition improved without undergoing liver transplantation.. ALF is a life-threatening condition, and HSV as an etiology must be suspected based on background, clinical manifestation, and laboratory information. The potential role of plasmapheresis in HSV hepatitis should be considered.

Topics: Acyclovir; Adult; Antiviral Agents; Female; Herpes Simplex; Herpesvirus 2, Human; Humans; Liver Failure, Acute; Plasmapheresis; Tomography, X-Ray Computed

The unexpected transmission of donor-derived infection through organ transplantation is a rare event with current donor screening practices. In this case report we describe a probable donor-derived transmission of Herpes Simplex Virus (HSV)-2 via deceased donor kidney transplantation resulting in HSV hepatitis in the recipient. This manifested as acute liver failure which resolved with appropriate anti-viral therapy. Following recovery from the acute liver insult, the patient developed fibrotic liver morphology and portal hypertension, an unusual departure from the typical course.

Topics: Acyclovir; Adult; Allografts; Antiviral Agents; Biopsy; Female; Hepatitis, Viral, Human; Herpes Simplex; Herpesvirus 2, Human; Humans; Hypertension, Portal; Kidney; Kidney Transplantation; Liver; Liver Cirrhosis; Liver Failure, Acute; Treatment Outcome

Although much less common than localized zoster, initial presentation of varicella-zoster virus (VZV) as visceral infection can occur especially after allogeneic hematopoietic stem cell transplantation (HSCT). We herein report a case of post-transplant visceral VZV infection presenting as fatal acute liver failure. It developed 4 years after allogeneic HSCT when a long-term prophylactic anti-VZV agent administration was discontinued. VZV should be listed as a causative pathogen of acute liver failure even years after allogeneic HSCT. Indication for, and duration of anti-VZV prophylaxis should be further investigated.

Topics: Acyclovir; Adult; Antiviral Agents; Female; Hematopoietic Stem Cell Transplantation; Herpes Zoster; Herpesvirus 3, Human; Humans; Liver Failure, Acute; Male; Middle Aged; Virus Activation; Young Adult

BACKGROUND Liver failure in the neonatal population is a life-threatening complication and has a wide array of etiologies, including infectious, immune-mediated, metabolic, or drug-induced. Although neonatal herpes simplex virus (HSV) hepatitis only accounts for 1% of all acute liver failures, it has an extremely aggressive clinical course that carries a mortality rate of 85%. CASE REPORT We report a rare case of disseminated neonatal HSV-2 with late presentation associated with fulminant liver failure. The patient recovered without obvious neurologic deficits or need for liver transplant. CONCLUSIONS This case study emphasizes and promotes awareness of early recognition and appropriate clinical management of neonatal HSV infection, and its positive outcome.

Topics: Acyclovir; Antiviral Agents; Herpes Simplex; Herpesvirus 2, Human; Humans; Infant, Newborn; Liver Failure, Acute; Male; Time-to-Treatment

Prognosis of hepatitis-associated aplastic anaemia (HAAA) was improved with haematopoietic stem cell transplantation (HSCT) and immunosuppression, but the long-term outcome remains undefined. Case 1: a girl aged 3 years with acute liver failure (ALF) submitted to orthotopic liver transplantation (OLT) subsequently developed aplastic anaemia and HSCT from a compatible sibling was performed. Post-HSCT, the patient developed post-transplant lymphoproliferative disorder and rituximab was administered with good response. Fifteen years later, both grafts show good outcome. Case 2: a girl aged 10 years submitted to OLT due to ALF, developed pancytopenia 2 months later. Due to the absence of a human leucocyte antigen compatible donor, she was treated with ciclosporin and antithymocyte globulin with very good long-term outcome. These clinical cases suggest that, for patients with HAAA that underwent OLT, aggressive therapy with HSCT or immunosuppression may provide a benign long-term outcome.

Topics: Acyclovir; Anemia, Aplastic; Antiviral Agents; Child; Child, Preschool; Diagnosis, Differential; Female; Follow-Up Studies; Hematopoietic Stem Cell Transplantation; Hepatitis; Humans; Liver Failure, Acute; Liver Transplantation; Postoperative Complications

Pyogenic tonsillitis may often be observed in the general Western population. In severe cases, it may require antibiotic treatment or even hospitalization and often a prompt clinical response will be noted. Here we present an unusual case of progressive multiple organ failure including fulminant liver failure following acute tonsillitis initially mistaken for "classic" pyogenic (that is bacterial) tonsillitis.. A 68-year-old previously healthy white man was referred with suspicion of pyogenic angina. After tonsillectomy, he developed acute liver failure and consecutive multiple organ failure including acute hemodynamic, pulmonary and dialysis-dependent renal failure. Immunohistopathological analysis of his tonsils and liver as well as serum polymerase chain reaction analyses revealed herpes simplex virus-2 to be the causative pathogen. Treatment included high-dose acyclovir and multiorgan supportive intensive care therapy. His final outcome was favorable.. Fulminant herpes simplex virus-2-induced multiple organ failure is rarely observed in the Western hemisphere and should be considered a potential diagnosis in patients with tonsillitis and multiple organ failure including acute liver failure. From a clinical perspective, it seems important to note that fulminant herpes simplex virus-2 infection may masquerade as "routine" bacterial severe sepsis/septic shock. This persevering condition should be diagnosed early and treated goal-oriented in order to gain control of this life-threatening condition.

Topics: Acute Disease; Acyclovir; Aged; Antiviral Agents; Critical Care; Herpes Simplex; Herpesvirus 2, Human; Humans; Liver; Liver Failure, Acute; Male; Multiple Organ Failure; Tonsillitis; Treatment Outcome

We present the case of a patient, with history of myelodysplastic syndrome and recent bone marrow transplant, who developed fulminant liver failure secondary to herpes simplex virus (HSV) hepatitis. His presentation was unique, as findings of liver microabscesses on computed tomography scan have not been described previously in this patient population. Despite initial treatment with acyclovir, he continued to deteriorate, and later sensitivities found the HSV strain to be resistant to acyclovir. HSV hepatitis with secondary liver failure is rare and, without appropriate treatment, its mortality is >80%. Early suspicion and immediate therapy are the keys to improve patient survival.

Topics: Acyclovir; Adrenal Cortex Hormones; Antiviral Agents; Bone Marrow Transplantation; Drug Resistance, Viral; Fatal Outcome; Foscarnet; Graft vs Host Disease; Hepatitis, Viral, Human; Humans; Liver; Liver Failure, Acute; Male; Middle Aged; Myelodysplastic Syndromes; Patient Comfort; Polymerase Chain Reaction; Simplexvirus; Transaminases; Transplantation, Homologous; Valacyclovir; Valine

Liver failure is a frequent and serious complication that causes morbidity and mortality in haematopoietic stem cell transplantation (HCT) recipients. Liver dysfunction in these patients can be related to infectious causes, most common viral hepatitis. We report a case of disseminated acyclovir-resistant herpes simplex virus (HSV) infection following HCT that led to acute liver failure and death. Although rare, HSV hepatitis leads to high morbidity and mortality and should be considered in the differential diagnosis of HCT recipients with marked elevation of hepatic transaminase. Acyclovir is a first-line therapy for HSV infection; however, acyclovir-resistant viral strains should be considered and alternative HSV therapies given in HCT recipients whose HSV infection does not improve on acyclovir therapy.

Topics: Acyclovir; Antiviral Agents; Diagnosis, Differential; Drug Resistance, Viral; Hepatitis, Viral, Human; Herpes Simplex; Herpesvirus 2, Human; Humans; Liver Failure, Acute; Male; Middle Aged; Tomography, X-Ray Computed; Valacyclovir; Valine

Disseminated herpes simplex virus (HSV) infection in neonates represents a devastating entity that yields high mortality. Acyclovir is the primary antiviral agent used to treat life-threatening HSV infections in neonates; however, even though the agent has reduced morbidity overall from these infections, mortality with disseminated disease remains high. Currently, to our knowledge, no data exist regarding therapeutic drug monitoring of acyclovir in the setting of extracorporeal life support (ECLS) or continuous renal replacement therapy (CRRT) coupled with ECLS. We describe the case of a 14-day-old female with disseminated HSV-1 infection that progressed to fulminant hepatic and renal failure, necessitating the use of ECLS for hemodynamic support and CRRT as a treatment modality for hepatic and renal failure. The standard dosage of acyclovir 20 mg/kg/dose intravenously every 8 hours had been initiated, but after conversion to ECLS and CRRT, the patient's dosage was increased to 30 mg/kg/dose every 8 hours. After a repeat viral load remained unchanged from the initial viral load at 1 × 10(8)  copies/ml, the patient was transitioned from intermittent dosing to a continuous infusion of acyclovir added to the dialysate solution for CRRT at a concentration of 5.5 mg/L. To provide an optimal outcome, dosing was designed to maintain acyclovir plasma concentrations of at least 3 mg/L in order to maintain an acyclovir concentration of at least 1 mg/L in the cerebrospinal fluid. The patient's acyclovir serum concentrations measured at 24 and 72 hours after starting continuous-infusion acyclovir via the dialysate were 8.8 and 5.3 mg/L, respectively, allowing for a continuous serum concentration above 3 mg/L. Unfortunately, before a repeat viral load could be obtained to assess the efficacy of the continuous infusion acyclovir, the patient experienced an intracerebral hemorrhage as a complication related to ECLS after which technological support was withdrawn. This is the first report to describe the pharmacokinetics of continuous-infusion acyclovir in a neonate receiving ECLS with concurrent CRRT. These data suggest that adding acyclovir to the dialysate fluid during CRRT is effective in achieving therapeutic drug concentrations despite the complications of adding ECLS and CRRT circuits to a small patient.

Topics: Acyclovir; Antiviral Agents; Drug Monitoring; Extracorporeal Circulation; Female; Herpes Simplex; Humans; Infant, Newborn; Liver Failure, Acute; Pregnancy Complications, Infectious; Renal Insufficiency; Renal Replacement Therapy

Herpes simplex virus (HSV) hepatitis is an uncommon cause of acute liver failure (ALF), primarily affecting immunocompromised patients. So far, 148 cases have been published, of which 9 underwent liver transplantation (LT). The reported post-transplant survival is poor, with over 60% dying in the first year. Dosing and duration of antiviral therapy after LT are not established. Concerns include both the risk of hepatic recurrence after LT and emergence of viral resistance during prolonged therapy. HSV DNA plasma levels might be helpful to monitor therapeutic response and guide duration of therapy. We present a case of ALF complicating a primary HSV-1 infection in an immunocompetent host, who required emergency LT. We further discuss the value of measuring serial HSV DNA plasma loads to monitor antiviral therapy.

Topics: Acyclovir; Antiviral Agents; DNA, Viral; Hepatitis; Herpes Simplex; Herpesviridae Infections; Herpesvirus 1, Human; Humans; Liver Failure, Acute; Liver Transplantation; Male; Middle Aged; Simplexvirus; Viral Load

Most adults are Varicella zoster virus (VZV)-positive at the age of 20 years. Some, however, remain antibody-negative and may develop primary chicken pox during adulthood. We report a patient with Williams-Campbell syndrome who underwent double-lung transplantation while being VZV-negative. One year after the successful procedure, he was admitted with fulminant hepatic failure and some cutaneous vesicles in his face. Despite a rapid diagnosis of VZV infection and treatment with acyclovir, his situation deteriorated within 24 hours and while awaiting an urgent liver transplantation, he developed multiple organ failure and died.

Topics: Acyclovir; Adult; Antiviral Agents; Bronchiectasis; Chickenpox; Fatal Outcome; Herpesvirus 3, Human; Humans; Liver Failure, Acute; Liver Transplantation; Lung Transplantation; Male; Multiple Organ Failure; Respiratory Insufficiency; Time Factors; Waiting Lists

Fulminant hepatic failure (FHF) is a rare but well-recognized complication of primary herpes simplex virus (HSV) infection in immunocompromised patients. Here, we report two cases of acute hepatitis and FHF secondary to primary HSV type 1 infection following renal transplantation in the absence of any mucocutaneous manifestation. High levels of HSV type-1 DNA were detected in the blood. Both patients were seronegative for HSV 1 and HSV 2 immunoglobulin G (IgG) before transplantation, whereas the donor of patient 1 was HSV 1 IgG-positive but had no viremia and the donor of patient 2 was HSV-seronegative. Patient 1 recovered with acyclovir and immunoglobulin whereas patient 2 did not respond and succumbed to death. HSV-seronegative patients are potentially at risk of developing severe primary HSV disease following transplantation, particularly in the absence of routine anti-viral prophylaxis. HSV infection should always be excluded in transplant patients with hepatic dysfunction.

Topics: Acyclovir; Adult; Antiviral Agents; Biopsy; Fatal Outcome; Female; Hepatitis, Viral, Human; Herpes Simplex; Herpesvirus 1, Human; Humans; Immunoglobulins, Intravenous; Immunosuppressive Agents; Kidney Transplantation; Liver Failure, Acute; Male; Middle Aged; RNA, Viral; Tomography, X-Ray Computed; Treatment Outcome

Topics: Acyclovir; Chlamydia trachomatis; Chlamydiaceae Infections; Female; Herpes Simplex; Herpesvirus 1, Human; Humans; Infant, Newborn; Infectious Disease Transmission, Vertical; Liver Failure, Acute; Pregnancy; Pregnancy Complications, Infectious; Sepsis

Acute liver failure (ALF) is rare in children but carries high mortality. Infectious complications (IC) in adults are an important cause of mortality; however, there are few data in the pediatric population. The aim of the study was to determine the incidence of IC and their effects on the outcome in children with ALF.. The present study is a retrospective review of the case records of children presenting with ALF to our center. All patients with ALF received antibiotics and antifungal as prophylaxis from day 1 and high-dose acyclovir was given to neonates only (stopped when herpes simplex was ruled out). Biochemical parameters, duration of ventilation and intensive care, overall hospital stay, and patient outcome were compared between patients with IC and non-IC.. A total of 145 children (78 boys), median (range) age 4.22 (1 day-16 years) years, were studied. Thirty-seven of 145 (25%) patients had proven IC. The predominant infections included 14 episodes of bacteremia in 13 patients and lower respiratory tract infection and urinary tract infection in 10 and 8 patients, respectively. IC occurred in patients after a median (range) duration of 16 (0-54) days of admission. Median (range) duration of hospital stay in patients with IC was 38 (1-201) days and was significantly higher than in those without IC (10 [1-74] days), P < 0.0001. Overall mortality was 21% (31), of which 7% (11) was from the IC group and 14% (20) from the non-IC group; the difference was not statistically significant.. Infections were more frequent after 2 weeks of admission. Patients with sepsis had longer hospital stays and prolonged ventilation. Invasive fungal infections were rare in pediatric ALF with adequate doses of antifungal prophylaxis.

Topics: Acyclovir; Adolescent; Anti-Bacterial Agents; Antifungal Agents; Bacteremia; Child; Child, Preschool; Female; Humans; Incidence; Infant; Infant, Newborn; Length of Stay; Liver Failure, Acute; Male; Mycoses; Respiratory Tract Infections; Retrospective Studies; Urinary Tract Infections; Ventilation

Herpes simplex virus (HSV) hepatitis has a fatal impact on the outcome of organ transplanted recipients. Here, we present a thought-provoking case of HSV hepatitis in a high-risk recipient after living-related liver transplantation (LRLT). A 1-month-old female newborn infant was affected by HSV encephalitis. Fulminant hepatic failure (FHF) of unknown etiology occurred suddenly at 4.4 years of age. Viral infections were ruled out as the cause of FHF. Intensive care including plasma exchange (PE) was started, and the preoperative treatments for ABO incompatibility were performed. Thereafter, LRLT was performed emergently. Although strong immunosuppression for ABO incompatibility was continued after LRLT, antibody-mediated rejection (AMR) occurred on postoperative day (POD) 4. PE was repeated and improvements were obtained. However, liver dysfunction appeared on POD 8. Histopathological findings of liver needle biopsy clearly revealed HSV hepatitis, although the results of HSV DNA and antibody titer in blood sample did not clearly indicate HSV infection. On POD 21, thrombotic microangiopathy (TMA) occurred and the plasma and immunoglobulin were replenished. Our pediatric recipient recovered successfully from AMR, HSV hepatitis, TMA, and repeated sepsis. We conclude that well considered therapy based on the real-time detection of HSV hepatitis is indispensable for the further improvements of outcome in HSV hepatitis after LRLT.

Topics: Acyclovir; Antiviral Agents; Child, Preschool; Encephalitis, Herpes Simplex; Female; Hepatitis, Viral, Human; Humans; Liver Failure, Acute; Liver Transplantation; Simplexvirus

Herpes simplex virus hepatitis is a rare but potentially fatal condition that usually affects the immunocompromised, including pregnant women. This case report details the course of fulminant hepatic failure in a woman at 31 weeks gestation resulting in emergent delivery of the fetus and liver transplant in the mother.

Topics: Acyclovir; Adult; Antiviral Agents; Cardiotocography; Cesarean Section; Female; Hepatitis, Viral, Human; Herpes Simplex; Herpesviridae Infections; Herpesvirus 2, Human; Humans; Infant, Newborn; Liver Failure, Acute; Liver Transplantation; Male; Pregnancy; Pregnancy Complications, Infectious

A 63-year-old woman treated with prednisone for sinusitis developed fulminant liver failure due to a clinically unsuspected primary varicella zoster virus infection. The diagnosis of herpetic hepatitis was made from a liver biopsy, and varicella zoster virus viremia was detected by polymerase chain reaction. She was treated successfully with transplantation and perioperative administration of acyclovir.

Topics: Acyclovir; Antiviral Agents; Biopsy; Chickenpox; Female; Herpesvirus 3, Human; Humans; Liver; Liver Failure, Acute; Liver Transplantation; Middle Aged; Polymerase Chain Reaction; Prednisone; Treatment Outcome

Neonatal disseminated herpes simplex virus (HSV) infection with acute liver failure (ALF) and neonatal hemophagocytic lymphohistiocytosis (HLH) are severe diseases. We recently experienced a male infant with HLH and ALF induced by HSV type 1 (HSV-1). The infant, born at 39 weeks of gestation by normal delivery, developed a fever on day 4. On day 9, laboratory investigations showed progressive liver dysfunction and coagulopathy, and the serum ferritin was excessively elevated. Furthermore, the blood levels of interleukin (IL)-6, IL-10, and interferon-gamma were also elevated. HSV-1 DNA was detected in the serum and cerebrospinal fluid by the real-time PCR method. A diagnosis of HLH was established based upon the following criteria: fever, splenomegaly, cytopenia (two cell lines), serum ferritin (> 500 mug/l) and hypofibrinogenemia (< 150 mg/dl). High-dose acyclovir therapy, steroid pulse therapy using methylprednisolone, high-dose gamma globulin therapy and a blood transfusion were given. The patient recovered without neurological deficit. Neonatal disseminated HSV infections may be complicated by the development of HLH and hypercyokinemia. If HLH is suspected, not only high-dose acyclovir therapy but also anti-cytokine therapy should be considered.

Topics: Acyclovir; Anti-Inflammatory Agents; Antiviral Agents; Blood Transfusion; Coma; Cytokines; DNA, Viral; gamma-Globulins; Glasgow Coma Scale; Herpes Simplex; Herpesvirus 1, Human; Humans; Infant, Newborn; Liver Failure, Acute; Liver Function Tests; Lymphohistiocytosis, Hemophagocytic; Male; Methylprednisolone

Acute liver failure (ALF) in neonates is rare but carries a high mortality without liver transplantation. Herpes simplex virus (HSV) is one of the microbes that more commonly causes ALF and is potentially treatable; hence, early diagnosis and treatment are important to avoid progression to liver failure.. We have analysed retrospectively the case notes of 11 patients with HSV-induced ALF. A history of possible herpes infection was elicited in 5 parents, but HSV had not been suspected clinically. All patients were asymptomatic when discharged from postnatal units and were presented with nonspecific symptoms of poor feeding and lethargy within 2 weeks from birth. Seven of the 11 patients had HSV-1 infection, 4 HSV-2. Only 2 patients who received early treatment with intravenous acyclovir survived.. HSV-related ALF in the neonatal period carries high morbidity and mortality and needs a high index of suspicion so that life-saving treatment can be started promptly. Both HSV-1 and HSV-2 can cause severe neonatal infection. It is important to recognise HSV infection in women of childbearing age and their sexual partners.

Topics: Acyclovir; Antiviral Agents; Female; Herpes Genitalis; Herpes Simplex; Herpesvirus 1, Human; Herpesvirus 2, Human; Humans; Infant, Newborn; Infectious Disease Transmission, Vertical; Liver Failure, Acute; Male; Pregnancy; Pregnancy Complications, Infectious; Retrospective Studies

We report 5 cases of acute liver failure related to herpes simplex (HSV) infection in 1 immunocompetent and 4 immunosuppressed patients. One patient was too ill for liver transplantation indication. Three patients, among the 4 listed, underwent liver transplantation. Three patients died 11 days to 1 year after transplantation and 2 patients died 2 to 3 days after admission. All presented with fever and none with skin lesions. The diagnosis of HSV-related hepatitis was made antemortem in only 2 patients on the basis of positive blood cultures and/or immunohistochemic findings. In the remaining patients, HSV diagnosis was made retrospectively on further histologic and virologic investigations. Primary HSV infection was certain or likely in all cases, including an HSV2 superinfection of an anti-HSV1-positive patient and two HSV superinfections of hepatitis B virus (HBV)-related chronic liver disease. In these latter patients, HSV diagnosis was totally unsuspected, despite fever. HSV superinfection has significantly contributed to liver dysfunction aggravation and death. In conclusion, the diagnosis of HSV hepatitis is difficult to establish in the absence of specific clinical signs. This may suggest the need for early administration of acyclovir in patients with suspected HSV hepatitis, without waiting for virologic confirmation. Diagnosis methods providing fast results (real-time polymerase chain reaction [PCR]) should be implemented.

Topics: Acyclovir; Adolescent; Adult; Antibodies, Viral; Biopsy; Diagnosis, Differential; Female; Follow-Up Studies; Herpes Simplex; Humans; Liver Failure, Acute; Liver Transplantation; Male; Middle Aged; Retrospective Studies; Simplexvirus; Treatment Outcome