Unusual Cause of Multisystem Organ Failure and Coma

Abstract

INTRODUCTION: Primary herpes simplex virus (HSV-1) infection typically involves mucosal sites. Disseminated infection to the central or peripheral nervous system (meningitis and encephalitis) or hepatitis are severe complications. Here we report an unusual case of disseminated HSV-1 infection in a healthy man involving the pharynx associated with documented viremia, encephalitis and hepatitis. CASE PRESENTATION: The patient is a 57 year old male who initially presented with chest pain and ultimately developed multisystem organ failure and encephalitis. The patient has a past medical history significant for coronary artery disease, hypertension and chronic kidney disease. The patient had coronary stent placement in 2006 but was non-compliant. The patient began to have chest pain reminiscent of his previous STEMI. Angiography demonstrated 100% occlusion of the right circumflex and proximal left coronaries. Patient underwent CABG after being medically optimized. On post-op day 5, the patient's creatinine spiked. Later the patient began to complain of odynophagia and began to spike fevers. ENT was consulted and fiberoptic scope demonstrated small ulcers in the pharynx. The patient became encephalopathic progressing quickly, requiring intubation for airway protection. The patient continued to spike fevers, and further workup consisting of a viral panel, EBV, CMV, hepatitis panel, HIV and toxoplasma were all found to be negative. One week post-op, the patient's liver function tests spiked with his AST and ALT being above 3000 and 4500 respectively. WBC was 2.3. At this point the patient was comatose, intubated and in multisystem organ failure. Liver biopsy was done as well as a lumbar puncture. HSV hepatitis was found on liver biopsy and the spinal fluid was positive for IgM HSV. Acyclovir was initiated and despite poor prognosis, the patient made full recovery. DISCUSSION: Complications of HSV are typically seen in immunocompromised patients. Immunocompetent patients can also suffer from viremia and dissemination. Symptoms vary but often involve skin findings (rash), mucocutaneous lesions, hepatitis, coagulopathy and acute kidney injury. Identification of cutaneous HSV with secondary dissemination may direct the early initiation of acyclovir therapy. The extent of disease at the initiation of acyclovir plays a large role in its effectiveness and outcomes improve with earlier initiation of therapy. CONCLUSIONS: Only 100 cases are reported in the literature with an incidence rate of 2 cases per million. Disseminated HSV, especially in an immunocompetent patient is uncommon and fatal if left untreated. Early initiation of acyclovir can maximize chance for survival.