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Case Reports
. 2023 Jul 12;23(1):465.
doi: 10.1186/s12879-023-08414-6.

Herpes simplex virus dissemination with necrotizing hepatitis following Descemet membrane endothelial keratoplasty

Ahad Azeem  1 , Brandon Baartman  2 , Christopher D Conrady  3 , Jeffery L Meier  4   5 , Rima El-Herte  6
Affiliations
Case Reports

Herpes simplex virus dissemination with necrotizing hepatitis following Descemet membrane endothelial keratoplasty

Ahad Azeem et al. BMC Infect Dis. .

Abstract

Background: Corneal transplants are the most common type of transplant and increasing in frequency. Donor cornea tissues are a rare source of herpes simplex virus (HSV) transmission and not routinely tested for presence of HSV. Donor graft-to-recipient transmission typically causes graft failure and anterior uveitis, and extra-ocular HSV disease has not been previously reported. We present a case of HSV transmission from donor cornea tissue that nearly cost the corneal transplant recipient his life.

Case report: An elderly immunocompetent man developed an acute illness 10 days after having donor corneal tissue implanted in a Descemet membrane endothelial keratoplasty (DMEK). He was found to have HSV necrotizing hepatitis per liver biopsy, trilineage cytopenia, rhabdomyolysis, acute kidney failure, altered mental status, early-stage hemophagocytic lymphohistiocytosis (HLH), and donor corneal tissue implant infection resulting in graft failure and anterior uveitis. HSV DNA was detected in cerebral spinal fluid, peripheral blood, explanted donor corneal tissue, and anterior chamber fluid (220 million HSV DNA copies per mL). HSV-1 seroconversion denoted a primary HSV infection, and the patient had no other risk factor for HSV acquisition. Early recognition of HSV dissemination prompting treatment with intravenous acyclovir, as well as a short course of HLH-directed therapy, resolved the systemic illness. Vision was restored to near normal by replacement of the infected corneal graft with new donor DMEK tissue in conjunction with intravitreal foscarnet treatment.

Conclusion: Awareness of the potential risk of donor cornea tissue transmitting HSV and leading to life-threatening HSV disease is paramount to early diagnosis and treatment. The role of donor cornea tissue in HSV transmission and disease merits additional attention and investigation.

Keywords: Cornea transplant; Corneal transplant infection; Hemophagocytic lymphohistiocytosis; Herpes keratitis; Herpes simplex hepatitis.

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Conflict of interest statement

Ahad Azeem - No conflict

Brandon Baartman - No conflict

Christopher D. Conrady - No conflict

Jeffery L. Meier - No conflict

Rima El-Herte - No conflict

Figures

Fig. 1
Fig. 1
Herpetic non-zonal necrotizing hepatitis. Hematoxylin and eosin stain of liver biopsy tissue
Fig. 2
Fig. 2
Evidence of HSV-1 in liver biopsy tissue by HSV-1-specific immunohistochemistry (brown color). Hematoxylin (blue) counterstain
Fig. 3
Fig. 3
Specular microscopy of the donated ocular tissue suspected to have transmitted the HSV. Healthy hexagonal endothelial cells can be appreciated with little dropout or signs of stress
See this image and copyright information in PMC

References

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