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HSV Hepatitis in Pregnancy
Abstract Number: SU-63
Abstract Type: Case Report/Case Series
Pregnant patients are at high risk of developing hepatitis/disseminated infection after acute HSV infection due to relatively impaired T-cell functioning. This is a very rare occurrence but can be life threatening, with mortality risk reported as high as 39%.1 We present a case of a previously healthy 21 y/o who developed HSV 2 hepatitis at 24 weeks of pregnancy.
A 21 y/o G4P2 at 24 weeks EGA presented to an outside hospital with lower abdominal and flank pain. She was febrile, tachycardic, and hypotensive and was transferred to our care for suspected sepsis secondary to pyelonephritis. After two days of ceftriaxone with no improvement, she was evaluated by Infectious Disease who recommended meropenem and vancomycin. Liver function tests showed mild transaminitis (AST/ALT 150/64). Workup for HIV and Influenza, hepatitis panel, and blood cultures were negative. General surgery was consulted but no evidence of cholecystitis or appendicitis was found. On day 6, patient’s blood work showed new onset thrombocytopenia and worsening anemia. Transaminitis continue to worsen with peak AST/ALT at 2197/498 associated with hyperbilirubinemia (3.0) and elevated LDH (2572). Diagnosis of HELLP versus HSV hepatitis was entertained. The patient was started on IV Acyclovir therapy. Despite this management, the patient’s septic shock continued to worsen. Based on her declining clinical picture, decision was made to proceed with cesarean delivery. General endotracheal anesthesia was induced with etomidate and succinylcholine. A male neonate with Apgars of 5/8 was transferred to the NICU. The patient was extubated on POD 1. HSV 2 PCR was positive. Additionally, workup for Varicella zoster, Parvovirus, Toxoplasma, Cytomegalovirus, Chlamydia, Gonorrhea, and ANA were all negative. On postpartum day 2 she developed altered mental status and remained febrile, with concern for delirium vs HSV encephalitis. Head CT and MRI were normal. Lumbar puncture was not performed due to patient’s elevated INR (peak 1.8). Her mental status continued to improve and she was discharged on post-op day 9 with plan for total of 2 weeks of IV Acyclovir, followed by high dose oral maintenance for HSV hepatitis.
The clinical presentation of febrile abdominal pain and anicteric hepatic dysfunction in pregnancy should prompt consideration of the diagnosis of herpes hepatitis.2 Since 1969, at least 35 cases of herpes hepatitis in pregnancy have been reported in the literature.1The risk seems to be higher during the third trimester of pregnancy.3 Our patient presented with fever and tachycardia which put an infectious process high up in the differential. With the onset of hepatic dysfunction, herpes hepatitis was considered and treatment with acyclovir immediately started.
1. Herrera 2013
2. Meagan 2014
3. Sappenfield 2013