PMC4719572_01
Hepatic (a-c) and tonsillar (d-e) histology. Liver biopsy tissue shows patchy necrosis comprising 20 to 30 % of the submitted tissue (a hematoxylin and eosin x100), with nuclear viral inclusions (b hematoxylin and eosin x400), immunohistochemically positive for herpes simplex virus-2 antigen (c x400). Tonsillar tissue examination discloses acute ulcerating tonsillitis (d hematoxylin and eosin x100) with patchy positivity for herpes simplex virus-2 antigen in some remnants of surface epithelium adjacent to the ulcer and in necrotic tissue overlying the ulcer (e x200). Photomicrographs were taken on a Zeiss Axiophot2 microscope
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Fig1
Initial histologic findings revealed diffuse hepatic necrosis compatible with viral hepatitis (Fig. 1); empirical antiviral treatment using ganciclovir (500 mg single-shot, followed by 450 mg twice a day) was commenced in order to cover cytomegalovirus (CMV) and herpes simplex virus (HSV). In addition, initial results showed seropositivity for HSV-2 immunoglobulin G (IgG), Epstein-Barr virus (EBV) IgG and CMV IgG. Due to strong HSV-positivity of hepatic tissue, tonsillar histologies were re-evaluated for HSV and marked respective immunopositivity was noted (Fig. 1).
Course of key laboratory parameters used to assess cellular damage and hepatic dysfunction in patient with multiple organ failure. Laboratory indices at respective days following intensive care unit admission. ALAT alanine aminotransferase, alk. alkaline, ASAT aspartate aminotransferase, GGT gamma-glutamyltransferase
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Fig2
Aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) serum levels peaked at day 3 (ASAT 6126U/l, ALAT 3377U/l), and elevated serum ammonia (123 mumol/l), alkaline phosphatase levels (520 U/l), and total bilirubin levels were noted (Fig. 2).
Eruptions demonstrating generalized herpetic rash at day 8 following intensive care unit admission (left thigh)
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Fig3
Over the ensuing days, a repeated generalized rash with herpetic vesicles under continued high-dose acyclovir treatment (initial dose of 2700 mg/day followed by 1500 mg/day for approximately 30 days with respective adjustment to renal function) was noted (Fig. 3).