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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e31820e6881
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Neonatal Herpetic Hepatitis

Nazareth, Kristina Marie; Ngo, Peter D

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Division of Pediatric Gastroenterology, Floating Hospital for Children at Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.

Address correspondence and reprint requests to Dr Peter D. Ngo, Floating Hospital for Children at Tufts Medical Center, 800 Washington St, Box 213, Boston, MA 02111 (e-mail: pngo@tuftsmedicalcenter.org).

The authors report no conflicts of interest.

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

A 15-day-old girl presented with failure to thrive and a 17% weight loss since birth. No prenatal or labor complications were noted. There was no fever, vomiting, ill contacts or rash, and no contributory family history. Notably, the patient failed her newborn hearing screen. On presentation, she had mild lethargy, poor feeding, and mild hepatomegaly. Laboratory work illustrated aspartate aminotransferase 512 (reference range 5–30 IU/L), alanine aminotransferase 491 (reference range 5–40 IU/L), normal bilirubin, and normal prothrombin time/partial thromboplastin time. Abdominal ultrasound showed multiple hypoechoic liver lesions (Fig. 1). Imaging of the kidneys, pancreas, and spleen was unremarkable. Lumbar puncture yielded a positive HSV (herpes simplex virus)-1 polymerase chain reaction (PCR), and she was diagnosed as having herpetic hepatitis. The patient had a rapid clinical response and improved transaminases soon after beginning acyclovir. Repeat imaging showed resolution of the lesions (Fig. 2).

Figure 1
Figure 1
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Figure 2
Figure 2
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HSV is a well-documented cause of failure to thrive (1). Most women who give birth to affected infants have no history of HSV. Up to 50% of these infants present without cutaneous lesions (2,3). Neonatal HSV hepatitis is frequently associated with acute liver failure and high mortality (1). The diagnosis, in the present case, was made by HSV PCR of the cerebrospinal fluid, which has been demonstrated to be superior to HSV serology in detecting the infection (4). Ultrasound findings seen here have been reported in adults with HSV hepatitis; however, limited imaging data are available in pediatrics (5–7). Previous case reports of herpetic hepatitis describe fulminant hepatitis with liver biopsies showing multiple necrotic areas, possibly consistent with the hypoechoic ultrasound lesions seen in this case (8).

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REFERENCES

1. Verma A, Dhawan A, Zuckerman M, et al. Neonatal herpes simplex virus infection presenting as acute liver failure: prevalent role of herpes simplex virus type I. J Pediatr Gastroenterol Nutr 2006; 42:282–286.

2. Morris S, Bauer H, Samuel M, et al. Neonatal herpes morbidity and mortality in California, 1995–2003. Sex Transm Dis 2008; 35:14–18.

3. Jones C. Vertical transmission of genital herpes. Drugs 2009; 69:421–434.

4. Puchhammer-Stockel E, Heinz F, Kundi M, et al. Evaluation of the polymerase chain reaction for diagnosis of herpes simplex virus encephalitis. J Clin Microbiol 1993; 31:146–148.

5. Wolfsen HC, Bolen JW, Bolen JL, et al. Fulminant herpes mimicking herpetic abscesses. J Clin Gastroenterol 1993; 16:61–64.

6. Mortele KJ, Barish MA, Yucel KE, et al. Fulminant herpes hepatitis in an immunocompetent pregnant woman: CT imaging features. Abdom Imaging 2004; 29:682–684.

7. Ak O, Uygur Bayramicili O, Ozer, S, Yilmaz B. A case of herpes simplex hepatitis with hepatic nodules in an immunocompetent patient. Turk J Gastroenterol 2007;18:115–118.

8. Benador N, Mannhardt W, Schranz D, et al. Three cases of neonatal herpes simplex virus infection presenting as fulminant hepatitis. Eur J Pediatr 1990; 49:555–559.

Copyright 2011 by ESPGHAN and NASPGHAN

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