acyclovir and Liver-Failure

Neonatal herpes simplex virus (HSV) is an uncommon but devastating infection in the newborn, associated with significant morbidity and mortality. The use of PCR for identification of infected infants and acyclovir for treatment has significantly improved the prognosis for affected infants. The subsequent use of suppressive therapy with oral acyclovir following completion of parenteral treatment of acute disease has further enhanced the long-term prognosis for these infants. This review article will discuss the epidemiology, risk factors and routes of acquisition, clinical presentation, and evaluation of an infant suspected to have the infection, and treatment of proven neonatal HSV disease.

Topics: Acyclovir; Antiviral Agents; Cesarean Section; Delivery, Obstetric; Disseminated Intravascular Coagulation; Encephalitis, Herpes Simplex; Extraction, Obstetrical; Extraembryonic Membranes; Female; Herpes Genitalis; Herpes Simplex; Herpesvirus 1, Human; Herpesvirus 2, Human; Humans; Infant, Newborn; Infectious Disease Transmission, Vertical; Keratitis, Herpetic; Labor, Obstetric; Liver Failure; Pregnancy; Pregnancy Complications, Infectious; Prognosis; Respiratory Insufficiency; Risk Factors; Skin Diseases, Viral; Time Factors

Topics: Acyclovir; Antiviral Agents; Herpes Simplex; Herpesvirus 1, Human; Humans; Immunocompetence; Immunoglobulins, Intravenous; Liver Failure; Male; Middle Aged; Valganciclovir

A young woman presented with a febrile illness in the third trimester of pregnancy. Laboratory investigation revealed severe acute hepatitis with thrombocytopenia and coagulopathy. Liver injury progressed despite emergent caesarian section and delivery of a healthy infant. Therefore, therapeutic plasma exchange (TPE) was performed on three consecutive days post-partum for a presumed diagnosis of acute liver failure (ALF) associated with pregnancy due to hemolysis, elevated liver enzymes, and low platelets (HELLP) or acute fatty liver of pregnancy (AFLP). Treatment with TPE was followed by biochemical and clinical improvement but during her recovery herpes simplex virus type 2 (HSV-2) infection was diagnosed serologically and confirmed histologically. Changes in the immune system during pregnancy make pregnant patients more susceptible to acute HSV hepatitis, HSV-related ALF, and death. The disease is characterized by massive hepatic inflammation with hepatocyte necrosis, mediated by both direct viral cytotoxicity and the innate humoral immune response. TPE may have a therapeutic role in acute inflammatory disorders such as HSV hepatitis by reducing viral load and attenuating systemic inflammation and liver cell injury. Further investigation is needed to clarify this potential effect. The roles of vigilance, clinical suspicion, and currently accepted therapies are emphasized.

Topics: Acute Disease; Acyclovir; Anti-Bacterial Agents; Antiviral Agents; Cesarean Section; Combined Modality Therapy; Dexamethasone; Emergencies; Female; Fetal Organ Maturity; Hepatitis, Viral, Human; Herpes Simplex; Humans; Hydrocortisone; Infant, Newborn; Liver Failure; Male; Plasma Exchange; Pregnancy; Pregnancy Complications; Pregnancy Complications, Infectious; Puerperal Disorders; Systemic Inflammatory Response Syndrome; Young Adult

Acute liver diseases of pregnancy are common and usually transient and reversible. Given the number of different possible diagnoses, performing a large biological screening and a proper iconographic documentation is key. It makes sure no etiology fatal to the mother and her fetus is missed.

Topics: Acyclovir; Adult; Antiviral Agents; Drug Resistance, Microbial; Female; Herpes Simplex; Humans; Liver Diseases; Liver Failure; Pregnancy; Pregnancy Complications; Pregnancy Trimester, Third

A 43-year-old Japanese woman underwent unrelated cord blood transplantation (CBT) during remission for acute lymphoblastic leukemia with t(4; 11)(q21;q23). Tacrolimus was given for prophylaxis of graft-versus-host disease. The posttransplantation clinical course was mostly uneventful, and the leukemia remained in remission. Fourteen months after CBT, the patient developed pancytopenia and hepatic dysfunction with persistent high-grade fever. The bone marrow was hypocellular with increased numbers of macrophages and hemophagocytes. The numbers of Epstein-Barr virus (EBV) copies in peripheral blood samples were remarkably high. Although the patient showed complete donor-type hematopoiesis, the titer of viral capsid antigen immunoglobulin G was low, and the results of a test for EBV nuclear antigen were negative. There was no clinical response to the reduction of immunosuppressive therapy or to the administration of high-dose methylprednisolone, human immunoglobulin, or acyclovir. The patient died 466 days after CBT of massive gastrointestinal hemorrhage due to bone marrow and hepatic failures. This case demonstrates that fatal EBV-associated hemophagocytic syndrome (HPS) can occur more than 1 year after CBT. This report is the first of a case of late-onset EBV-associated HPS following CBT.

Topics: Acyclovir; Adult; Anti-Inflammatory Agents; Antibodies, Viral; Antiviral Agents; Bone Marrow Diseases; Epstein-Barr Virus Infections; Epstein-Barr Virus Nuclear Antigens; Female; Hematopoiesis; Hemorrhage; Herpesvirus 4, Human; Humans; Immunoglobulin G; Liver Failure; Lymphohistiocytosis, Hemophagocytic; Methylprednisolone; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Time Factors; Transplantation Chimera

Herpes simplex virus (HSV) hepatitis in pregnant women is a rare condition. We report a case confirmed by liver biopsy and successfully treated with empiric intravenous acyclovir.. A 25-year-old primigravida at 34 weeks of gestation presented with fever, thrombocytopenia, and markedly elevated liver enzymes. The patient was treated empirically and was delivered by cesarean. After delivery failed to correct her condition, a liver biopsy revealed HSV hepatitis. The fetus was unaffected and the patient recovered with an extended course of acyclovir.. Pregnant women are susceptible to disseminated HSV causing hepatitis. A high index of suspicion is necessary to diagnose HSV hepatitis and begin appropriate treatment with acyclovir. Herpes simplex virus hepatitis should be included in the differential diagnosis for liver failure during pregnancy.

Topics: Acyclovir; Adult; Antiviral Agents; Biopsy; Cesarean Section; Diagnosis, Differential; Female; Hepatitis, Viral, Human; Herpes Simplex; Humans; Liver; Liver Failure; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Simplexvirus; Thrombocytopenia

Topics: Acyclovir; Diagnosis, Differential; Female; Hepatitis, Viral, Human; Herpes Simplex; Herpesvirus 2, Human; Humans; Infant, Newborn; Infectious Disease Transmission, Vertical; Liver Failure; Liver Transplantation; Pregnancy

Although exceedingly rare, fulminant hepatic failure (FHF) in immunocompetent patients can develop with primary or recurrent infection due to herpes simplex virus (HSV). The diagnosis is frequently obscured by the absence of mucocutaneous involvement. Elevated transaminase values with leukopenia and a relatively low bilirubin level may provide clues to the diagnosis. We describe an immunocompetent woman who died of FHF before a definitive diagnosis of HSV type 2 hepatitis was established. Herpes simplex virus hepatitis is one of the few causes of FHF for which potentially effective therapy is available. Thus, early diagnosis is paramount and usually requires liver biopsy. Recent studies suggest that transjugular liver biopsy is safe and effective in establishing the cause of FHF. Since the diagnosis and management of FHF are frequently influenced by the results of transjugular liver biopsy, it may become a standard diagnostic tool for managing FHF in centers where such expertise exists.

Topics: Acyclovir; Antiviral Agents; Fatal Outcome; Female; Herpes Genitalis; Humans; Immunocompetence; Liver; Liver Failure; Middle Aged

Herpes simplex-induced fulminant hepatitis is an infrequently reported cause of hepatitis in adults. Pregnant females and patients with impaired cellular immunity may be at increased risk, although healthy adults have been affected. The diagnosis may be underrecognized due to nonspecific presenting symptoms and lack of typical cutaneous herpes lesions. We present three cases of fatal herpes simplex fulminant hepatitis. Our review of case reports of herpes simplex hepatitis in adults demonstrates improved survival with intravenous acyclovir therapy. We believe that empiric use of acyclovir should be considered while the diagnostic evaluation of non-acetaminophen-induced fulminant hepatitis is underway. Recognition of characteristic liver function abnormalities seen with fulminant herpes simplex hepatitis include marked elevation of transaminases with AST > ALT and a mild hyperbilirubinemia (anicteric hepatitis), and they should prompt acyclovir therapy. This is especially true when there are no obvious risk factors for other forms of hepatitis.

Topics: Acyclovir; Adult; Aged; Fatal Outcome; Female; Herpes Simplex; Humans; Injections, Intravenous; Liver Failure; Male; Middle Aged

The emergency department (ED) evaluation of the neonate with sepsis or symptoms suggesting sepsis usually includes a complete blood count, catheterized urinalysis with culture, blood cultures, cerebrospinal fluid analysis and culture, and possibly a chest radiograph. Admission for observation for neonates at high risk for sepsis is universal. Depending on the patient's presentation and the preference of the admitting physician, intravenous antibiotics are started. Typically, ampicillin and either an aminoglycoside or cefotaxime are chosen because they cover the likely pathogens in this age group, ie, group B streptococci, Escherichia coli and other gram-negative enterics, and Listeria monocytogenes. Coverage for viral infection, most notably herpes simplex virus (HSV), is only rarely instituted in the ED and is usually considered if the patient has obvious ulcerative lesions or if the mother has known HSV infection. Unfortunately, antiviral therapy with acyclovir or vidaribine has to be started in the early stages of infection to be effective. If antiviral therapy is started after viral entry into cells, morbidity is severe and mortality approaches 80%. Neonates who survive are usually severely disabled. Broadening the indications for initiating antiviral therapy to include the neonate whose mother has any history of a sexually transmitted disease may prevent the sequelae of untreated or inadequately treated HSV infection. A case is reported of an 8-day-old girl who developed disseminated HSV infection and died as a result of hepatic failure.

Topics: Acyclovir; Antiviral Agents; Disseminated Intravascular Coagulation; Emergency Treatment; Fatal Outcome; Female; Herpes Simplex; Humans; Infant, Newborn; Liver Failure; Patient Selection; Sepsis