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Disseminated herpes simplex infection induced hepatitis during pregnancy mimicking HELLP syndrome, a diagnostic challenge.

ABSTRACT: The disseminated herpes simplex virus 2 (HSV-2) carries a high mortality rate in pregnant women if left unrecognized. It often presents as unrelieved fever and hepatitis. Diagnosis is challenging due to vague symptoms and potential overlap with other conditions. Pregnancy is a risk factor as it conforms to a partially immunocompromised state. Dissemination to the brain could be devastating, and the treatment requires intravenous antivirals like acyclovir. Fetal outcomes are variable based on previous case reports. We present a case of young female gravida 1 para 1 who presented with disseminated HSV infection mimicking HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome. She responded well to intravenous acyclovir, and the fetus had a viable outcome at the 26th week of gestation. Early diagnosis can prevent progression to fulminant liver failure and the need for a liver transplant.

SUBMITTER: Ali H

PROVIDER: S-EPMC10699672 | biostudies-literature | 2022 Mar

REPOSITORIES: biostudies-literature

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Disseminated herpes simplex infection induced hepatitis during pregnancy mimicking HELLP syndrome, a diagnostic challenge.

Ali Hassam H Kumar Shruthi S Kratzer Mary-Kate MK Kinderwater Josef J

Infectious medicine 20220106 1

The disseminated herpes simplex virus 2 (HSV-2) carries a high mortality rate in pregnant women if left unrecognized. It often presents as unrelieved fever and hepatitis. Diagnosis is challenging due to vague symptoms and potential overlap with other conditions. Pregnancy is a risk factor as it conforms to a partially immunocompromised state. Dissemination to the brain could be devastating, and the treatment requires intravenous antivirals like acyclovir. Fetal outcomes are variable based on pre ...[more]

PMID: 38074975

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Project description:PurposeThis case report describes a case of Horner syndrome resulting from central nervous system (CNS) toxoplasmosis in an immunocompromised patient. Horner Syndrome is a neurological condition characterized by unilateral miosis, ptosis with apparent enophthalmos, and anhidrosis due to inhibition of the sympathetic pathway. The ocular sympathetic pathway runs from the posterolateral hypothalamus to the ophthalmic branch of the trigeminal nerve (cranial nerve V1). Central nervous system (CNS) toxoplasmosis infection is typically only seen in immunocompromised patients. To our knowledge, toxoplasmosis has never been reported as a cause of Horner syndrome.ObservationsA forty-four-year-old Caucasian male was admitted to the hospital for left upper extremity paresthesias, gait instability, and painful vesicular skin lesions, and Horner syndrome. Upon review, he had an 18-year history of HIV initially controlled on anti-retrovirals but had been lost to follow-up for several years until he developed severe headaches determined to be caused by Toxoplasmosis lesions in his brain. Over several months he was treated for the Toxoplasmosis but had poor adherence to medications. After subsequent admission and workup, we found multi-focal ring enhancing lesions on MRI in the basal ganglia, hypothalamus, thalamus, and internal capsule. We postulated that the hypothalamic lesion was the cause of his Horner syndrome. After treatment for both toxoplasmosis and HSV his Horner syndrome and other neurologic symptoms resolved.Conclusions and importanceThis is the first reported case of Horner syndrome resulting from CNS toxoplasmosis. This case report and the accompanying questions provide an opportunity to review and explore the neuroanatomy and subtle symptomatic differences between various etiologies of Horner syndrome (primary, secondary, tertiary) in the context of a novel presentation. In conclusion, toxoplasmosis should be considered when investigating Horner syndrome in immunocompromised patients.

Project description:BackgroundPre-eclampsia is a relatively common complication of pregnancy. HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a severe manifestation of pre-eclampsia with significant morbidity and mortality for pregnant women and their children. Corticosteroids are commonly used in the treatment of HELLP syndrome in the belief that they improve outcomes.ObjectivesTo determine the effects of corticosteroids on women with HELLP syndrome and their children.Search strategyWe searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2010).Selection criteriaRandomized controlled trials comparing any corticosteroid with placebo, no treatment, or other drug; or comparing one corticosteroid with another corticosteroid or dosage in women with HELLP syndrome.Data collection and analysisTwo review authors assessed trial quality and extracted data independently.Main resultsEleven trials (550 women) compared corticosteroids with placebo or no treatment. There was no difference in the risk of maternal death (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.28 to 3.21), maternal death or severe maternal morbidity (RR 0.27, 95% CI 0.03 to 2.12), or perinatal/infant death (RR 0.64, 95% CI 0.21 to 1.97). The only clear effect of treatment on individual outcomes was improved platelet count (standardized mean difference (SMD) 0.67, 95% CI 0.24 to 1.10). The effect on platelet count was strongest for women who commenced treatment antenatally (SMD 0.80, 95% CI 0.25 to 1.35).Two trials (76 women) compared dexamethasone with betamethasone. There was no clear evidence of a difference between groups in respect to perinatal/infant death (RR 0.95, 95% CI 0.15 to 6.17) or severe perinatal/infant morbidity or death (RR 0.64, 95% CI 0.27 to 1.48). Maternal death and severe maternal morbidity were not reported. In respect to platelet count, dexamethasone was superior to betamethasone (MD 6.02, 95% CI 1.71 to 10.33), both when treatment was commenced antenatally (MD 8.10, 95% CI 6.23 to 9.97) and postnatally (MD 3.70, 95% CI 0.96 to 6.44).Authors' conclusionsThere was no clear evidence of any effect of corticosteroids on substantive clinical outcomes. Those receiving steroids showed significantly greater improvement in platelet counts which was greater for those receiving dexamethasone than those receiving betamethasone. There is to date insufficient evidence of benefits in terms of substantive clinical outcomes to support the routine use of steroids for the management of HELLP. The use of corticosteroids may be justified in clinical situations in which increased rate of recovery in platelet count is considered clinically worthwhile.

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Disseminated herpes simplex infection induced hepatitis during pregnancy mimicking HELLP syndrome, a diagnostic challenge.

Publications

Disseminated herpes simplex infection induced hepatitis during pregnancy mimicking HELLP syndrome, a diagnostic challenge.

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