Acute hepatitis in pregnancy – the truth is more than skin deep

Herpes Simplex Virus (HSV) Hepatitis – Clinical Presentation

Back to the case

In our clinical case above, our patient presented with an anicteric severe hepatitis which would make acute hepatitis E less likely (typically presents with jaundice). The presentation with fever and upper respiratory infection symptoms makes pregnancy-related conditions such as acute fatty liver of pregnancy or HELLP syndrome less likely. Complicated gallstone disease is common in pregnancy and should be considered given her RUQ pain and fever, however her severe hepatitis, leukopenia, and thrombocytopenia makes this diagnosis unlikely. Given her clinical presentation, HSV hepatitis should be strongly suspected and empiric acyclovir should be started while awaiting additional diagnostics.

Two great reviews of acute hepatitis in pregnancy can be seen in the 2015 ACG Clinical Guideline: Liver Disease and Pregnancy and the 2020 AASLD Practice Guidance: Reproductive Health and Liver Disease (see Figure 1). 

An approach to abnormal liver enzymes in pregnancy is also reviewed in a recent Liver Fellow Network post.

Figure 1: Evaluation of abnormal liver tests pregnancy

Taken from: Sarkar, M., et al., Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology, 2020. Epub ahead of print.

HSV Hepatitis – Diagnostics  

Figure 2: HSV hepatitis on liver biopsy

Taken from: WebPathology – Visual Survey of Surgical Pathology, Herpes Simplex Virus Hepatitis.

Back to the case

In our clinical case above, our patient was started on empiric acyclovir and underwent a transjugular liver biopsy to rule out other potential etiologies of acute hepatitis. An example of HSV hepatitis on liver biopsy pathology above shows evidence of hemorrhagic and coagulative necrosis with multinucleated hepatocytes with ground-glass appearance suggestive of viral inclusions. 

HSV Hepatitis – Treatment

  • High dose IV acyclovir should be started once HSV hepatitis is suspected.
  • Acyclovir has been shown to be safe and well-tolerated in pregnancy and during lactation.
  • Early acyclovir treatment is associated with improved outcomes in HSV hepatitis including improved mortality and reduced need for liver transplantation
  • The duration of anti-viral therapy is unclear but should be guided by clinical factors such as improvement in liver enzyme tests, negative serum PCR, and improvement in symptoms
  • Acyclovir-resistance should be considered in patients who are not improving on acyclovir therapy, and use of additional agents such as foscarnet should be considered under the guidance of infectious disease consultation

Leave a Reply

Your email address will not be published. Required fields are marked *