Answer to the last #DiagnosticDilemma
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The answer to the last Diagnostic Dilemma (A 31-year-old woman presented with fever, right-upper-quadrant abdominal pain, and hepatitis; ALT 629 units/L and AST 634 units/L. She had recently been sexually active with a new male partner. During laparoscopy, numerous lesions on the surface of the liver were found. What is the likely diagnosis?) is B.Herpes simplex virus type 2

On examination, the author found the patient to be febrile (temperature 38·2°C). She was tachycardic (heart rate 120 beats per min), tachypnoeic (respiratory rate 44 breaths per min), and was tender in her right upper quadrant. She was not jaundiced and there were no mucocutaneous lesions seen anywhere. Laboratory investigations showed a hepatitic picture: alanine aminotransferase was 629 units per L, aspartate aminotransferase 634 units per L, gamma-glutamyl transferase 182 units per L, alkaline phosphatase 143 units per mL, and a total bilirubin concentration within normal limits. The patient's C-reactive protein concentration was 192 mg/L. An abdominal ultrasound showed pericholecystic fluid and biliary sludge in a thin-walled gallbladder. admitted her with a presumed diagnosis of cholecystitis. However, during abdominal laparoscopy, the author found numerous vesicles across the surface of the liver—with no evidence of cholecystitis. Histological analysis of a liver biopsy sample showed a lobular parenchymal lymphocytic inflammatory infiltrate; herpes simplex virus type 2 (HSV-2) was detected by PCR.

She was treated with intravenous acyclovir followed by oral valacyclovir for 6 weeks after which she made a complete recovery; laboratory investigations returned to normal levels. Notably, having been seronegative at presentation, the patient was found to have seroconverted after 4 weeks showing convalescent type-specific serology—HSV-2 IgG. Subsequent testing of her asymptomatic partner found that he was also HSV-2 IgG positive. Hepatitis A, B, C, D, and E are the most frequent causes of viral hepatitis. Primary HSV-2 should be considered as a cause of acute hepatitis—even in the absence of jaundice or mucocutaneous lesions and if the patient is immunocompetent. A viral prodrome with a headache and fever is common. Transmission may occur via asymptomatic viral shedding in sexually active individuals. In the acute stages of the illness, PCR is the diagnostic method of choice as patients have usually not seroconverted. The high mortality of patients with untreated HSV-2 hepatitis is greatly reduced with early intravenous acyclovir treatment.

Source: The Lancet
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