Herpes Simplex Virus Type 2 Hepatitis: An Uncommon Cause of Persistent Fever in a Late Post-Transplant Liver Recipient

Objective: Rare disease Background: Herpes simplex virus (HSV) is a rare cause of hepatitis. HSV hepatitis can be life-threatening due to its rapid progression to liver failure if not treated on time. It affects primarily immunocompromised individuals but can also present in immunocompetent hosts. HSV hepatitis in solid organ transplant recipients usually occurs in the early post-transplant period as fulminant hepatitis. We present a rare case of febrile anicteric HSV2 hepatitis occurring late in the post-transplant period, with only mild elevation in transaminase levels. Case Report: A 60-year-old man presented to the Emergency Department with generalized weakness, chills, and fever for 1 day. His medical history included Crohn's disease, primary sclerosing cholangitis, liver transplantation, and cholangiocarcinoma. Initial laboratory findings revealed leukocytosis. Extensive workup did not reveal a clear etiology of persistent fever. Liver enzymes peaked to aspartate transaminase 198 U/L and alanine transaminase 135 U/L, suggesting possible hepatitis. Liver biopsy showed focal areas of necrosis with vague histiocyte collections. Liver biopsy tissue was positive for HSV2 by polymerase chain reaction; therefore, HSV2 hepatitis diagnosis was made. Intravenous acyclovir was initiated for treatment of HSV2 hepatitis, which resulted with fever resolution within 48 h of initiation and return of liver enzymes to normal levels. Conclusions: This case highlights the importance of having a high suspicion of HSV hepatitis as a rare cause of persistent fevers in immunosuppressed, post-transplant patients even in the late post-transplant period and in the absence of mucocutaneous lesions. Prompt recognition of this disease is crucial to start prompt treatment and decrease mortality.