SHM Converge Scientific Abstract ePoster Gallery-A Unique Case of Disseminated Herpes Simplex Virus-2: Acute Hepatitis and Hemophagocytic Lymphohistiocytosis

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This case describes a 30-year-old immunocompetent woman who developed severe disseminated HSV-2 infection with acute hepatitis and concern for hemophagocytic lymphohistiocytosis (HLH). She initially had two weeks of fever and flu-like symptoms treated as a respiratory illness with prednisone, hydroxychloroquine, and doxycycline. Her fevers persisted, and she later developed severe abdominal pain. On hospital presentation, she had intermittent high fever, tachycardia, abdominal distention, epigastric tenderness, and a painful genital ulcer.<br /><br />Workup showed marked liver injury with AST around 3000 and ALT around 1500, along with ascites, hepatomegaly, and lymphadenopathy on CT. HSV-2 was confirmed from the genital ulcer swab and blood HSV PCR was positive, supporting disseminated infection and viremia. Because of concern for HLH, a bone marrow biopsy showed hemophagocytosis, and she received one dose of dexamethasone. After transfer to an academic center, Infectious Disease noted that HSV PCR cycle threshold values suggested higher-than-expected viral burden for a simple mucocutaneous infection, making HSV hepatitis more likely.<br /><br />She improved clinically and biochemically with IV acyclovir, then was discharged on valacyclovir.<br /><br />Key teaching points:<br />- HSV can present variably and may mimic nonspecific viral illness when mucocutaneous lesions are absent.<br />- Primary HSV-2 infection usually causes painful genital ulcers, fever, and tender inguinal lymphadenopathy, but disseminated disease can rarely cause hepatitis or neurologic complications.<br />- HSV hepatitis is difficult to diagnose, often lacks classic mucocutaneous findings, and can overlap with HLH criteria.<br />- Early viral testing is important in unexplained acute hepatitis or liver failure.<br />- Untreated HSV hepatitis has very high mortality, so empiric acyclovir should be considered when suspicion is present.

Asset Subtitle

Kathleen D. Aldrich

Meta Tag

Author List Anushua Bhattacharya, Kathleen D. Aldrich, Tyler Kristoff

Category Clinical Vignettes

Concept HSV-2 Infection

Concept Herpes Simplex Virus Hepatitis

Concept Clinical Presentation

Concept Acute Liver Failure

Concept Secondary hemophagocytic lymphohistiocytosis

Distinguished Non-Finalist

Presenter Organization University of North Carolina School of Medicine

Presenting Author Kathleen D. Aldrich

Track Adult

Keywords

HSV-2

disseminated herpes simplex

HSV hepatitis

acute hepatitis

hemophagocytic lymphohistiocytosis

genital ulcer

viremia

acyclovir

valacyclovir

immunocompetent woman

HSV-2 Infection

Herpes Simplex Virus Hepatitis

Clinical Presentation

Acute Liver Failure

Secondary hemophagocytic lymphohistiocytosis