02 December 2024
: Case report 
Herpes Simplex Virus Type 2 Hepatitis: An Uncommon Cause of Persistent Fever in a Late Post-Transplant Liver Recipient
Challenging differential diagnosis, Unusual setting of medical care, Rare disease
Tatjana Gavrancic ABCDEF 1, Kassandra Stoddard BCDE 2, Jason Lewis BD 3, Marko Gorasevic BE 4, Aleksandra Murawska Baptista F 1, Melissa Cortes F 1, Michael Smerina EF 1, Ricardo J. Pagan F 1, Adrian Dumitrascu EF 1, Libardo Rueda Prada
DEF 1*
DOI: 10.12659/AJCR.945140
Am J Case Rep 2024; 25:e945140
Table 1. Summary of laboratory and imaging workup.
| Laboratory workup (normal values) | Time of admission | Day 4* | Day 5* | Day 6* | Day 12* | Day 14: 2 days after antiviral treatment | 4 weeks after hospital discharge |
|---|---|---|---|---|---|---|---|
| Leukocytes (3.4–9.6×10/L) | 11.7 | 1.6 | 2.3 | 1.9 | 2.2 | 2.9 | 4.1 |
| Absolute neutrophil count (1.56–6.45×10/L) | 9.50 | 1.53 | 1.03 | 1.12 | 1.52 | 2.30 | 2.63 |
| Hemoglobin (13.2–16.6 g/dL) | 9.8 | 7.5 | 8.6 | 7.9 | 7.7 | 7.2 | 9.5 |
| Platelet count (135–317×10/L) | 187 | 98 | 100 | 95 | 106 | 123 | 129 |
| AST (8–48 U/L) | 48 | 174 | 175 | 198 | 118 | 60 | 48 |
| ALT (7–55 U/L) | 57 | 126 | 138 | 135 | 143 | 112 | 49 |
| Total bilirubin (<1.2 mg/dL) | 0.6 | 0.5 | 0.4 | 0.5 | 0.5 | 0.5 | 0.4 |
| PT (9.4–12.5 s)/INR (0.9–1.1) | 17.3/1.6 | – | 27.3/2.5 | – | 18.9/1.7 | 23.3/2.1 | 14.7/1.1 |
| Ferritin (24–336 mcg/L) | 2507 | – | 5425 | – | – | – | – |
| Fever workup on admission | Peripheral blood cultures: No growth. Urine culture: No growth. MRSA PCR swab: negative. Hepatitis A antibodies: negative. Hepatitis B serology: nonimmune. Hepatitis C antibody screen: negative. Epstein-Barr Virus PCR <2000 copies/mL | ||||||
| Imaging workup on admission | Chest X-ray: no acute abnormalities. CT of abdomen and pelvis with IV contrast: Interval pancreaticoduodenectomy and retroperitoneal lymphadenopathy with postoperative changes, without changes related to an acute intraabdominal infection. Ultrasound abdomen limited with abdominal Doppler: small thrombus within a superior mesenteric venous branch | ||||||
| Additional fever workup | Stool enteric pathogen culture stool: negative. ESR 16 (0–22 mm/1 h). Creatine kinase 41 (39–308 U/L). LDH 309 (122–222 U/L). QuantiFERON TB gold negative. HIV Ag/Ab screen: negative. Antinuclear Ab 0.9 (≤1.0 U). Rheumatoid factor 14 (<15 IU/mL). Serum electrophoresis: no apparent monoclonal protein. Serum free light chains: negative. CMV DNA PCR undetected. Adenovirus plasma PCR negative. HTLV I/II DNA not detected. Peripheral blood flow cytometry: no abnormal cells. Bone marrow biopsy: Polytypic B lymphocytes and no increase in blasts. Cryptococcal serum Ag: negative. Toxoplasma serum Ab: negative. Parvovirus B19 serum Ab: IgG positive, IgM negative. Parvovirus B19 PCR negative. Varicella-Zoster Ab negative. West and East Equine encephalitis serum Ab negative. St Louis Encephalitis serum Ab negative. Bartonella Ab panel negative. HSV1 blood PCR negative. Liver biopsy: please see . HSV2 blood PCR positiveFigure 1 | ||||||
| Additional imaging workup | CT chest without IV contrast: No pulmonary mass or consolidation. Transthoracic echocardiogram: No valvular heart disease or pericardial effusion. No intracardiac mass or thrombus. Venous ultrasound lower and upper extremities: negative for deep venous thrombosis. MRI abdomen without and with IV contrast: No evidence of hepatic abscess. Inflammatory appearing enhancement of the central liver favored to reflect posttreatment change. Brain MRI without and with IV contrast: Chronic small vessel disease and no other acute change. PET CT whole body FDG: Generalized moderate uptake throughout porta hepatis and adjacent hepatic parenchyma which is likely reactive to surgery. A few nonenlarged FDG avid mediastinal, right supraclavicular and left cervical lymph nodes which are likely reactive as well | ||||||
| * Days 4 to 12 are prior to antiviral treatment. Antiviral treatment was started on day 14. Ab – antibody; ALT – alanine transaminase; AST – aspartate transaminase; HSV – herpes simplex virus; CMV – cytomegalovirus; ESR – erythrocyte sedimentation rate; INR – international normalized ratio; LDH – lactate dehydrogenase; MRSA – methicillin-resistant ; PT – prothrombin time; PCR – polymerase chain reaction; MRI – magnetic resonance imaging; PET CT – positron emission tomography-computed tomography; FDG – fluorodeoxyglucos. | |||||||