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SJS Jan-04 HSV HEPATITIS Kaufman B, et al. Herpes simplex virus hepatitis: case report and review. Clin Infect Dis 1997;24:334-8. Take home points: 1. Hepatitis is an uncommon manifestation of HSV infection in adults (more common in patients with cellmediated immunity and in pregnant women) 2. Usually presents with non-specific symptoms early and quickly becomes fulminant hepatitis. Look for transaminases in the 1000s. >90% are anicteric. 3. Diagnose with liver biopsy and treat with acyclovir. Epidimiology: • Hepatitis is an uncommon manifestation of HSV • Usually occurs in neonates or malnourished children; rare in adults • Most adult patients are immunocompromised (most often deficiency cell-mediated immunity) or pregnant, but HSV hepatitis has been described in immunocompetent patients • Can occur with HSV-1 or HSV-2 Pathophysiology: possible mechanisms • Large HSV inoculum at the time of initial infection may result in dissemination with involvement of the liver • Virulence of HSV may be enhanced by activation of latent infection by reinfection with HSV • There may be some HSV strains that have affinity to the liver (“hepatovirulent”) Clinical features: • When hepatitis does occur due to HSV, it is frequently fulminant • Early on, signs and symptoms are non-specific; therefore HSV hepatitis is difficult to diagnose • Look for fever, anorexia, n/v, abdominal pain, leukopenia, and coagulopathy • Skin, mouth, and/or genital lesions are present in 57% of patients with HSV hepatitis • Typical LFT pattern is marked rise in transaminase levels without elevated bilirubin (most patients do not have jaundice). • Once fulminant hepatic failure sets in, most patients have a clinical picture of septic shock Diagnosis: • Liver biopsy is the only way to make a definitive diagnosis Treatment: • IV acyclovir (or any other antiviral effective against HSV)