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Fatal Liver Failure After Herpes-Simplex-Virus-2-Induced Acute Necrotizing Hepatitis: A Case Report
Thomas Rösner1, Julia Grenz2, Marlene Schaumäker2
1Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany.
Case Reports in Hepatology
|July 31, 2025
Summary
Fulminant acute liver failure (ALF) from disseminated herpes simplex virus type 2 (HSV2) occurred in a patient on JAK inhibitor therapy. Early antiviral intervention is crucial for immunocompromised patients with potential herpesvirus infections.
Area of Science:
- Hepatology
- Virology
- Immunology
Background:
- Herpes simplex virus (HSV) infections are common but disseminated disease and HSV hepatitis leading to acute liver failure (ALF) are rare.
- Immunocompromised individuals, especially transplant recipients, are at higher risk for severe HSV infections.
- Janus kinase (JAK) inhibitors may increase the risk of opportunistic infections like HSV.
Observation:
- A 50-year-old male with rheumatoid arthritis on upadacitinib (a JAK inhibitor) developed severe oropharyngeal mucositis and hepatic encephalopathy.
- Initial labs revealed bicytopenia, elevated liver enzymes and bilirubin, coagulopathy, and high HSV2 viral load.
- Liver biopsy confirmed extensive necrosis with HSV staining.
Findings:
- The patient presented with fulminant ALF due to disseminated primary HSV2 infection.
- Despite empirical treatment including intravenous aciclovir and plasmapheresis, the patient's condition rapidly deteriorated.
- High HSV2 viral load suggested antiviral resistance, and the patient was deemed untransplantable, ultimately dying from refractory shock.
Implications:
- This case highlights a rare instance of fulminant ALF caused by HSV2 hepatitis in a patient on JAK inhibitor therapy (upadacitinib).
- It underscores the importance of considering primary herpesvirus infections in the differential diagnosis of ALF, particularly in immunocompromised patients.
- Early diagnosis and prompt antiviral treatment are critical for improving outcomes in such cases.
