Disseminated Herpes Simplex Masquerading as Hemophagocytic Lymphohistiocytosis: A Case Report

Abstract

Introduction: Marked elevation in serum ferritin levels may be seen in disseminated infection or severe organ failure states, but it is also present in hemophagocytic lymphohistiocytosis (HLH). Herpes simplex virus (HSV) hepatitis has a high mortality rate, even in immunocompetent individuals, in whom it is rarely reported. We present a case of hyperferritinemia with features initially suggestive of a diagnosis of HLH but that ultimately proved to be fulminant HSV hepatitis.

Case presentation: A 56-year-old man with an indolent undiagnosed brain mass presented with progressive neurologic deficits and was found to have fevers, cytopenias, transaminitis, and hyperferritinemia. Initially, HLH was suspected; however, the ultimate diagnosis was HSV hepatitis with dissemination. Although the patient was treated with intravenous acyclovir, multiorgan failure developed, and he died.

Discussion: This case highlights the importance of considering alternative causes for a rise in ferritin levels when HLH is on the differential. Additionally, we discuss the diagnostic and therapeutic implications of HSV hepatitis, and we review the literature for cases presenting in immunocompetent hosts.

Figure 1

Skin lesions consisting of small erythematous and hemorrhagic papules, pustules, and vesicles present on the face, consistent with a diagnosis of herpes simplex virus infection.

Figure 2

Timeline of the case. ALT = alanine aminotransferase; AST = aspartate aminotransferase; BA = before admission; HD = hospital day; HSV = herpes simplex virus; IV = intravenous; MRI = magnetic resonance imaging; PCR = polymerase chain reaction; PET/CT = positron emission tomography/computed tomography.