Case Presentation: A 24 year old pregnant female at 23 weeks gestation presented with complaints of fevers and fatigue. She was treated symptomatically and discharged home. Two weeks later, the patient developed encephalopathy, profound liver failure, and thrombocytopenia, resulting in induction of labor and loss of the infant. She was subsequently intubated and developed shock requiring pressors as well as Molecular Adsorbent Recirculating System (MARS) dialysis for support. Cultures were collected, including a HSV panel, which was positive for HSV-1 on PCR. Acyclovir was initiated with subsequent clinical improvement resulting in downtrend of her liver enzymes and HSV viral load and eventual extubation. The patient appeared to return to baseline, however days later she developed jaundice, ascites with evidence of spontaneous bacterial peritonitis, and encephalopathy refractory to lactulose and rifaximin. Despite acyclovir, broad-spectrum antibiotics, and prior MARS therapy, her liver enzymes worsened again resulting in multiorgan failure and she eventually expired from multiorgan failure
Discussion: Herpes simplex virus (HSV) hepatitis is a rare but potentially fatal presentation of HSV that can affect immunocompromised individuals such as pregnant women, particularly in the third trimester. It can lead to liver failure with mortality rates up to 75%. Early recognition with the initiation of antivirals and supportive therapy have been shown to reduce mortality, however insult to the liver can lead to liver failure complicated by encephalopathy and ascites. We present a case of HSV hepatitis in pregnancy which despite supportive therapy and acyclovir, resulted in demise.
Conclusions: This case demonstrates a rare occurrence of HSV hepatitis in a pregnant woman. Recognition of HSV occurred once the patient developed acute liver failure and encephalopathy, however based on her history she likely presented with HSV symptoms, including fevers and fatigue that remained untreated. Despite supportive therapy such as MARS and acyclovir, the patient expired of liver failure from HSV. This case shows the importance of considering HSV in the pregnant population, for if it were recognized and treated earlier, the patient may not have reached fulminant liver failure resulting in death. In conclusion, HSV hepatitis and initiation of early antiviral therapy should be considered in all pregnant patients with concern for evolving hepatic failure.