(1421) Herpetic Hepatitis Post-Liver Transplantation: A Rare Fatal Complication

Introduction: Over the past decade, outcomes for liver transplantation continue to improve with better harvesting and surgical techniques, enhanced immunosuppression and anti-microbial coverage. We present a case of fulminant hepatic failure post liver transplantation due to herpes simplex virus (HSV) hepatitis.

Description: Our patient was a 37 year old man with a history of primary sclerosing cholangitis (PSC) and autoimmune hepatitis for which he underwent a living donor liver transplantation. This was complicated by recurrent PSC of the allograft, along with development of chronic thrombi of his portal veins. Given his deteriorating health, he was relisted for a deceased donor liver transplant and portal vein thrombectomy. Within two weeks of the second transplant he developed a fever and rapidly progressive hemodynamic instability with evidence of worsening transaminitis. Imaging modalities such as chest X-ray, hepatic ultrasound and computed tomography of the chest, abdomen and pelvis did not reveal a source of infection. A liver biopsy with staining demonstrated necrosis with surrounding hemorrhage, confirmed to be HSV hepatitis. Notably he was on oral prophylactic acyclovir at this time, which was subsequently switched to intravenous therapeutic acyclovir. Within the next few days, the patient developed hemorrhagic shock attributed to HSV induced disseminated intravascular coagulation. Attempts to surgically control the bleeding proved futile. The family and all teams involved deemed it was in the patient’s best interest to transition to comfort care, the patient passed with family at bedside.

Discussion: There are only a few case reports of HSV hepatitis post liver transplantation. Ours was interesting in that the patient was on prophylactic acyclovir when he developed fulminant HSV hepatitis. His profound immunosuppressed state in the early post transplant period very likely contributed to the virulent nature of the infection. Delayed recognition of this rare complication is associated with high mortality. Literature supports prompt diagnosis and early pharmacological treatment with intravenous acyclovir, cidofovir or foscarnet to improve outcomes. A high index of suspicion for HSV hepatitis in high-risk patients is essential in the setting of worsening post transplant transaminitis.