title: Acute liver failure caused by herpes simplex virus in a pregnant patient: is there a potential role for therapeutic plasma exchange?
abstract: A young woman presented with a febrile illness in the third trimester of pregnancy. Laboratory investigation revealed severe acute hepatitis with thrombocytopenia and coagulopathy. Liver injury progressed despite emergent caesarian section and delivery of a healthy infant. Therefore, therapeutic plasma exchange (TPE) was performed on three consecutive days post-partum for a presumed diagnosis of acute liver failure (ALF) associated with pregnancy due to hemolysis, elevated liver enzymes, and low platelets (HELLP) or acute fatty liver of pregnancy (AFLP). Treatment with TPE was followed by biochemical and clinical improvement but during her recovery herpes simplex virus type 2 (HSV-2) infection was diagnosed serologically and confirmed histologically. Changes in the immune system during pregnancy make pregnant patients more susceptible to acute HSV hepatitis, HSV-related ALF, and death. The disease is characterized by massive hepatic inflammation with hepatocyte necrosis, mediated by both direct viral cytotoxicity and the innate humoral immune response. TPE may have a therapeutic role in acute inflammatory disorders such as HSV hepatitis by reducing viral load and attenuating systemic inflammation and liver cell injury. Further investigation is needed to clarify this potential effect. The roles of vigilance, clinical suspicion, and currently accepted therapies are emphasized.
authors.affiliation: Division of Hepatology, Department of Transplantation, California Pacific Medical Center (CPMC), San Francisco, California.
authors.forename: Edward W
authors.initials: EW
authors.lastname: Holt
authors.forename: Jennifer
authors.initials: J
authors.lastname: Guy
authors.forename: Shelley M
authors.initials: SM
authors.lastname: Gordon
authors.forename: Jan C
authors.initials: JC
authors.lastname: Hofmann
authors.forename: Richard
authors.initials: R
authors.lastname: Garcia-Kennedy
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Steady
authors.forename: Natalie H
authors.initials: NH
authors.lastname: Bzowej
authors.forename: R Todd
authors.initials: RT
authors.lastname: Frederick
mesh_terms: D000208:Acute Disease; D000212:Acyclovir / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use; D002585:Cesarean Section; D003131:Combined Modality Therapy; D003907:Dexamethasone / Q000627:therapeutic use; D004630:Emergencies; D005260:Female; D005325:Fetal Organ Maturity; D006525:Hepatitis, Viral, Human / Q000150:complications* / Q000188:drug therapy / Q000628:therapy; D006561:Herpes Simplex / Q000150:complications* / Q000188:drug therapy / Q000628:therapy; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D007231:Infant, Newborn; D017093:Liver Failure / Q000209:etiology* / Q000628:therapy; D008297:Male; D010951:Plasma Exchange; D011247:Pregnancy; D011248:Pregnancy Complications / Q000209:etiology*; D011251:Pregnancy Complications, Infectious; D011644:Puerperal Disorders / Q000188:drug therapy / Q000628:therapy; D018746:Systemic Inflammatory Response Syndrome / Q000188:drug therapy / Q000209:etiology / Q000628:therapy; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D000998:Antiviral Agents; D003907:Dexamethasone; D006854:Hydrocortisone; D000212:Acyclovir
keywords: acute liver failure; hepatitis; herpes simplex; pregnancy; therapeutic plasma exchange