Fulminant hepatic and multiple organ failure following acute viral tonsillitis: a case report

Abstract

Background: Pyogenic tonsillitis may often be observed in the general Western population. In severe cases, it may require antibiotic treatment or even hospitalization and often a prompt clinical response will be noted. Here we present an unusual case of progressive multiple organ failure including fulminant liver failure following acute tonsillitis initially mistaken for "classic" pyogenic (that is bacterial) tonsillitis.

Case presentation: A 68-year-old previously healthy white man was referred with suspicion of pyogenic angina. After tonsillectomy, he developed acute liver failure and consecutive multiple organ failure including acute hemodynamic, pulmonary and dialysis-dependent renal failure. Immunohistopathological analysis of his tonsils and liver as well as serum polymerase chain reaction analyses revealed herpes simplex virus-2 to be the causative pathogen. Treatment included high-dose acyclovir and multiorgan supportive intensive care therapy. His final outcome was favorable.

Conclusions: Fulminant herpes simplex virus-2-induced multiple organ failure is rarely observed in the Western hemisphere and should be considered a potential diagnosis in patients with tonsillitis and multiple organ failure including acute liver failure. From a clinical perspective, it seems important to note that fulminant herpes simplex virus-2 infection may masquerade as "routine" bacterial severe sepsis/septic shock. This persevering condition should be diagnosed early and treated goal-oriented in order to gain control of this life-threatening condition.

Fig. 1

Hepatic (a-c) and tonsillar (d-e) histology. Liver biopsy tissue shows patchy necrosis comprising 20 to 30 % of the submitted tissue (a hematoxylin and eosin ×100), with nuclear viral inclusions (b hematoxylin and eosin ×400), immunohistochemically positive for herpes simplex virus-2 antigen (c ×400). Tonsillar tissue examination discloses acute ulcerating tonsillitis (d hematoxylin and eosin ×100) with patchy positivity for herpes simplex virus-2 antigen in some remnants of surface epithelium adjacent to the ulcer and in necrotic tissue overlying the ulcer (e ×200). Photomicrographs were taken on a Zeiss Axiophot2 microscope

Fig. 2

Course of key laboratory parameters used to assess cellular damage and hepatic dysfunction in patient with multiple organ failure. Laboratory indices at respective days following intensive care unit admission. ALAT alanine aminotransferase, alk. alkaline, ASAT aspartate aminotransferase, GGT gamma-glutamyltransferase

Fig. 3

Eruptions demonstrating generalized herpetic rash at day 8 following intensive care unit admission (left thigh)