Case Presentation: A 19-year-old, 22-week pregnant woman with no significant past medical history presented with cough, fever, myalgia, abdominal pain and diarrhea for two weeks. On admission, she was febrile to 101.2 F and tachycardic with HR of 110-120 bpm. Physical exam revealed right upper quadrant (RUQ) tenderness upon palpation and one vesicular genital lesion. Labs were significant for ALT 688 U/L, AST 1749 U/L, ALP 213 U/L and total bilirubin at 0.8 mg/dL. Viral hepatitis panel was negative and RUQ ultrasound was significant for diffuse hypoechoic liver parenchyma with echogenic portal triads supportive of acute hepatitis. Due to concern for herpes simplex virus type 2 hepatitis (HSV2), she was started on prophylactic treatment with intravenous (IV) acyclovir. Two days later, her Herpes IgM resulted positive and IgG negative. Swab of her genital lesion also tested positive for HSV2. She continued IV acyclovir with noted significant downtrend of liver function tests and clinical improvement. Ultimately, she was discharged on PO acyclovir to complete a prolonged treatment course.
Discussion: Given the significant mortality associated with HSV2 hepatitis, especially in pregnant or immunocompromised patients, it is crucial for physicians to maintain high clinical suspicion. For this group of patients presenting with evidence of acute hepatitis, it is recommended to start IV acyclovir (10 mg/kg every 8 hours) while awaiting confirmatory laboratory testing, which can take a few days to return. Polymerase chain reaction of whole blood is preferred to liver biopsy as it is less invasive and highly accurate. It is important to recognize that most patients present with non-specific flu-like symptoms, which makes diagnosis challenging. Therefore, early management is key in order to prevent complications such as fulminant hepatitis and to ensure the survival of the mother and fetus. This case highlights the importance of maintaining clinical suspicion when managing acute hepatitis in immunocompromised and pregnant patients and creates awareness of this condition.
Conclusions: HSV-2 hepatitis in pregnancy is a rare, but serious condition with a high mortality rate. This case highlights the importance of early suspicion for HSV-2 hepatitis and prophylactic treatment with IV Acyclovir in a pregnant patient with severe liver dysfunction. Early management aids in an increased rate of survival and decrease prolonged hospital stay.