Herpes simplex virus hepatitis after solid organ transplantation in adults

Abstract

Twelve patients developed herpes simplex (HSV) hepatitis a median of 18 days after solid organ transplantation. This is earlier than cytomegalovirus hepatitis, which usually occurs 30-40 days after transplantation. Eight recipients (67%) died, and in seven, the diagnosis was made at autopsy or less than 48 h before death. Clinical manifestations associated with mortality were hypotension, disseminated intravascular coagulation (DIC), metabolic acidosis, gastrointestinal bleeding, and bacteremia. Laboratory abnormalities at diagnosis associated with mortality were high creatinine, low platelet counts, prolonged partial thromboplastin time, and a high percentage of band forms on the blood smear. Disseminated HSV disease was noted in four of six patients who had an autopsy and included involvement of lungs in three and the gastrointestinal tract in three. Five recipients developed DIC and all died. Pathologically, HSV hepatitis has two forms, focal and diffuse. All three patients with diffuse liver pathology died. However, three of seven with focal liver pathology survived with antiviral therapy, which suggests that early diagnosis and treatment may be lifesaving. None of these patients had received prophylactic acyclovir. It is possible that acyclovir prophylaxis may be able to prevent this disease.

Figure 1

Diagnosis of herpes simplex virus (HSV) hepatitis (12 patients) and cytomegalovirus (CMV) hepatitis (35 patients) by days after transplantation.

Figure 2

Liver specimens showing diffuse and focal hepatitis. Left, macroscopic specimen (2900 g) with diffuse necrosis due to herpes simplex virus (HSV) hepatitis (patient 4, table 1). Middle and bottom: micrographs of hematoxylin- and eosin-stained sections. Middle left and right: section of above specimen showing diffuse HSV hepatitis of the portal zone (original magnification, ×42) and typical intranuclear herpetic inclusions (×170) , respectively. Bottom left and right: liver biopsy (patient 8, table 1) showing focal HSV hepatitis (×42) and typical intranuclear herpetic inclusions (×110), respectively.