Acute liver failure due to herpes simplex virus: diagnostic clues and potential role of plasmapheresis

Abstract

Introduction: Acute liver failure (ALF) is a life-threatening condition that remains challenging for physicians despite several advances in supportive care. Etiologies vary worldwide, with herpes simplex virus (HSV) hepatitis representing less than 1% of cases. Despite its low incidence, ALF is a lethal cause of acute necrotizing hepatitis and has a high mortality. Early antiviral treatment is beneficial for survival and decreased liver transplantation necessity. However, plasmapheresis, despite its theoretical potential benefit, is scarcely reported. Patient concerns: A 25-year-old woman with no known disease presented with painful pharynx ulcers, increased transaminases and impaired liver function. Diagnosis:ALF due to a disseminated HSV-2 primary infection was diagnosed with a positive polymerase chain reaction for HSV-2 in the biopsied liver tissue and blood. Interventions: Empiric antiviral treatment was initiated. After clinical deterioration, plasmapheresis was also initiated. Outcomes: After 6 cycles of plasmapheresis and supportive care, the patient’s condition improved without undergoing liver transplantation. Conclusions: ALF is a life-threatening condition, and HSV as an etiology must be suspected based on background, clinical manifestation, and laboratory information. The potential role of plasmapheresis in HSV hepatitis should be considered. Abbreviations: AC = amoxicillin–clavulanate, ALF = acute liver failure, ALT = alanine aminotransferase, AST = aspartate aminotransferase, DILI = drug-induced liver injury, HSV = herpes simplex virus, ICU = intensive care unit, PCR = polymerase chain reaction.