Case Presentation: A 59 year-old man presents with epigastric and chest pain for 6 days. He has past medical history of childhood meningoencephalitis resulting in mild mental delay. He does not smoke, nor drink alcohol and denies any illicit drug use. He is single, never married. He recently moved to an assisted living facility where he started a relationship with a female resident. He reports to kissing her but has never been sexually active. In fact, this was his first oral contact with another individual. His speech is slow and deliberate which is near baseline for patient per his family. He has tachycardia and otherwise normal heart sounds. He has fine rales in the bilateral lung bases. He also has epigastric and right upper quadrant abdominal tenderness but no hepatosplenomegaly is noted. There are no skin lesions. His platelets are 97thou/cu mm, aspartate aminotransferase is 515u/L, and alanine aminotransferase is 361u/L, and alkaline phosphatase 54u/L, total bilirubin 0.7mg/dL. Previous records show normal transaminases in past. Urine drug screen, alcohol, acetaminophen and salicylate are negative. Serology for acute hepatitis viral infections is negative. Hepatobiliary ultrasonography is normal. His serum Ferritin is 25835ng/mL and transferrin saturation is 65%. He was initially thought to have hemochromatosis but hemochromatosis DNA mutation analysis is negative. Multiple diagnostic tests are sent for uncommon causes of acute hepatitis. His aminotransferases continue to increase. His liver biopsy demonstrates patchy lobular necrosis with positive Herpes simplex virus (HSV) I/II immunohistochemistry is in the areas of necrosis. HSV DNA polymerase chain reaction results as positive for HSV type 1.  Patient is started on IV acyclovir and his condition and liver function tests improved. He is discharged home on oral antivirals.

Discussion: Acute hepatitis is a commonly encountered problem for hospitalists. There are multiple causes of acute hepatitis. Herpes simplex is a rare but, fatal cause of acute hepatitis. It was thought to be transmitted by oral-oral contact (kissing) in this case. This contact was initially not given importance as the patient reported not being sexually active. Identifying detailed social and sexual risk factors can results in early diagnosis and testing of patients with acute HSV hepatitis. This case also demonstrates that elevated ferritin can result in premature closure as his initial diagnosis was thought to be hemochromatosis. Ferritin is an acute phase reactant and is nonspecific. It can be elevated in any acute hepatitis, viral infection or other inflammatory process.

Conclusions: Hospitalists should; 1) recognize that herpes simplex is a rare cause of acute hepatitis, 2) detect social and sexual risk factors which can results in early diagnosis of acute herpes virus hepatitis, 3) understand that ferritin can be elevated in any acute hepatitis and may be related to etiologies other than hemochromatosis.