Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

The Curious Case of a Post-Partum Fever
Hines, A., DO; Gopalakrishnan, P., MD
Kent Hospital, Warwick, RI
Introduction: Herpes Simplex Virus (HSV) hepatitis is a rare condition that is uncommon in
immunocompetent patients, but is being increasingly reported in pregnancy. Because the
signs and symptoms of HSV are non-specific, the diagnosis is often delayed or missed,
with 58% of HSV hepatitis cases being diagnosed at autopsy. HSV hepatitis, if left
untreated in the pregnant patient, has approximately 39% mortality rate for both mother and
fetus.
Case: A 33-year-old female, three days post-partum, presented to the ED with a three-day
history of persistent fevers that began intra-partum. Her newborn son was also febrile. She
had a spontaneous vaginal delivery at 37’2 weeks after premature rupture of membranes
and was treated with five doses of ampicillin given concern for chorioamnionitis, as her
GBS status was unknown. The patient was otherwise asymptomatic and had been treating
her fevers with acetaminophen at home. On initial evaluation she was found to have a
fever of 39.6C with a benign physical exam. Initial work-up, including CBC, CMP, and panculturing,
were negative. She was admitted for presumptive endometritis and started on
clindamycin and ampicillin. Two days into her stay she continued to spike fevers up to
39.2C despite antibiotic coverage. She remained asymptomatic. Further work-up to rule out
abscess in the setting of vaginal delivery and fevers, including abdominal ultrasound and
CT of the abdomen and pelvis, were unremarkable. On day three of hospitalization, the
patient’s AST rose to 171 and ALT to 126. She was also noted to have a 20% bandemia.
On day four, the patient’s AST climbed to 428 and ALT to 283. That same day it was
reported that her newborn infant, who was also hospitalized, was septic and was diagnosed
with pneumonia. HSV-1 was isolated from his endotracheal tube. At this time, empiric
acyclovir was added to the patient’s regimen. On day five, her AST peaked at 728 and ALT
at 481. Her bandemia also increased to 35%. Approximately 36 hours after initiation of
acyclovir, on day six of admission, her AST and ALT dropped significantly and continued to
trend down each day. Her fevers also subsided. The endometrial biopsy that was
performed on day four of admission revealed HSV, although her IgG and IgM serum
antibodies were negative for HSV-1 and HSV-2. Nine days after delivery her infant passed
in the NICU thought secondary to disseminated HSV. The patient was discharged home to
grieve the loss of her son. She completed a ten-day total course of acyclovir outpatient and
had return of normal LFTS sixteen days after admission.
Discussion: Our patient was sero-negative for HSV when she was initially evaluated, and
instead suspicion was made for the infection when her son was found to have HSV-1 on his
endotracheal tube (until later confirmed by her endometrial biopsy). Only 50% of HSV
cases present with the classic mucocutaneous lesions, with the most common presentation
being fever. During pregnancy, T-cell mediated immunity is suppressed which can promote
systemic effects of infections like HSV. The greatest risk for poor outcome is thought to be
associated with primary infections towards the end of pregnancy. Typically HSV-2
infections are a more common cause of HSV hepatitis, however, our patient likely had
HSV-1. Given the potentially dire consequences of HSV hepatitis, including need for liver
transplant and death, it is important to have a high clinical suspicion for the condition in the
right clinical setting, such as a pregnant patient with fever and transaminitis in the third
trimester with unclear source. Mortality rates, for both mother and fetus, are substantially
decreased when acyclovir therapy is initiated.