A 23-year-old female was admitted for severe abdominal pain and fulminant hepatic failure.
She had been followed in hematology clinic after an allogeneic stem cell transplant for acute lymphocytic leukemia done 6 months prior. Repeated episodes of graft versus host disease of the gut had prompted periods of high-dose corticosteroid therapy with the current prednisone dose being 40 mg per day.
On admission, the patient was in acute distress with midepigastric pain, prostration and fever of 39°C. Bowel sounds were normal. The abdomen was distended and without rebound tenderness, though with some guarding. A few small vesicles were noted on the anterior abdomen but no other rash was noted.
Blood chemistries showed an AST, 5600 U/L; ALT, 3630 U/L; total bilirubin, 2.2 mg/dL, with a direct of 1.9 mg/dL; alkaline phosphatase, 276 mU/mL; and partial thromboplastin time (PTT), 44 sec. Amylase and lipase were normal.
Blood CMV PCR negative.
Hepatitis B surface antigen and blood HBV PCR negative.
Hepatitis C antibody and blood PCR negative.
She was born in Guatemala but had lived in the United States for five years. The most likely diagnosis is which of the following?
0% Graft versus host disease of the liver
0% Herpes simplex virus hepatitis
0% Disseminated BK virus
0%Hepatitis B
Herpes simplex hepatitis should be considered when there is marked transaminase elevations in a patient who is either pregnant or immunosuppressed. Onset is sudden with fever, abdominal pain and profound rises in aminotransferases. There are usually no active signs of herpes simplex in the oral mucosa, vagina or skin.
There may be a role for measuring blood HSV DNA level but diagnosis can also be made by in liver tissue collected by biopsy, or at transplantation or autopsy, or in this case, possibly from the skin vesicles.
The dramatic elevations of ALT and AST in this case are incompatible with the other diagnoses listed except hepatitis B but that disease is excluded by a negative HBsAg and negative blood HBV PCR.
Adenovirus can cause fulminant hepatitis in HSCT patients but is not offered as a choice here.