acute hepatitis due to simplex in adult · acute hepatitis due to herpes simplex virus in anadult...

J. clin. Path. (1969), 22, 60-66

Acute hepatitis due to Herpes simplex virusin an adult

T. H. FLEWETT, R. G. F. PARKER, AND W. M. PHILIP

From East Birmingham Hospital, Birmingham

SYNOPSIS A case is described of herpetic hepatitis in a pregnant woman with primary herpeticstomatitis. Intranuclear inclusion bodies and virus particles were found in hepatocytes, and herpesvirus was isolated from a liver biopsy and from oral swabs but not from blood. From rising titresof neutralizing and complement-fixing antibody it is concluded that the oral infection was a primaryone. Factors predisposing to the hepatitis are discussed.

Acute hepatitis due to the virus of Herpes simplexdoes not appear to have been hitherto reported inadults, though the condition has been well describedin infants, in whom it presents as an acute fatalinfection occurring soon after birth. It has been re-ported in older children (up to the age of 5) whowere suffering from kwashiorkor (malignant malnu-trition) by Becker, Naude, Kipps, and McKenzie(1963) and by Kipps, Becker, Wainwright, andMcKenzie (1967). We describe below a case in apregnant woman in whom the diagnosis wasestablished by liver biopsy and virus isolation.She survived the infection.

CASE REPORT

A 24-year-old housewife was admitted on 10 May 1965to the East Birmingham Hospital in the 28th week ofher second pregnancy. She had been in good healthuntil seven days before her admission when she beganto vomit and at the same time complained of sore throatand mouth, constipation, backache, and anorexia.For this she was given oral tetracycline and trifluo-perazine (Stelazine). Her condition deteriorated rapidlyon the day of admission when her doctor found herdehydrated, jaundiced, and collapsed.On admission she was collapsed and stuporous with a

temperature of 100-40F, pulse rate 144, blood pressure135/70 mm Hg. Positive physical findings were severeherpetic ulceration of the mouth and fauces, slighticterus, and a uterus enlarged to the size of a sevenmonths' pregnancy. The faeces were pale. On the negativeside there were no localizing signs in the central nervoussystem, the liver and spleen could not be felt, and rectalexamination was negative.

Preliminary investigation showed a white blood countof 7,500 with 5% myelocytes and 3% metamyelocytes.Received for publication 22 May 1968.

There were occasional nucleated red cells, and plateletswere reduced to 80,000. Marrow puncture excluded thepossibility of leukaemia, the picture being quite normal.The possibility of hepatitis was suggested by our col-

league Dr Felix-Davies, and as it seemed important toknow the liver histology he was asked to do a liverbiopsy: steroids might well have been beneficial if thiswere an acute yellow atrophy but would be contraindi-cated for herpetic hepatitis. Histological examination offrozen sections of this biopsy showed small intranuclearinclusions in hepatocytes surrounding small areas ofnecrosis. The appearances were strongly suggestive ofherpes hepatitis.The correct diagnosis was therefore made within 24

hours of the patient'sadmissionand it was decided to treather primarily by adjusting the electrolyte and fluidbalance using intravenous fluids, including an adequatecalorie intake in the form of fructose. She also receivedampicillin six hourly, nystatin and gentian violet for hermouth, and 500 mg of gamma globulin on 12 May.The blood urea level fell from 105 to 12 mg/100 ml in

five days, gradually rising to 25 on the last estimation.Alanine aminotransferase (SGPT) (E.C. code no. 2.6.1.2.)fell from 220 to 40 R.F. u/ml serum in four days, risingto 95 on the 14th day, perhaps due to absorption fromthe dead foetus. Bilirubin similarly fell from 6-8 mg/100ml serum, the level on admission. The primitive whitecell count reached a maximum of 15% of circulatingleucocytes on the second day and 6% of all circulatingnucleated cells were normoblasts. A further liver biopsyon 20 August showed normal histology.The patient's clinical course was equally dramatic and

after being desperately ill for three or four days shesteadily improved and was delivered of a maceratedfoetus on 2 June. When seen in the Out-patient Depart-ment six weeks after admission she was in normalhealth, the lesions in the mouth having recovered com-pletely.

Since then she has given birth after a normal preg-nancy to a normal child.

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Acute hepatitis due to Herpes simplex virus in an adult

HISTOLOGICAL EXAMINATION OF THELIVER BIOPSY

METHOD The liver biopsy was fixed in 6% glut-araldehyde in M/30 cacodylate buffer, pH 7-2, for twohours. After fixation, some pieces which appearedabnormal to the naked eye were cut into pieces notmore than 1 mm cube, further fixed in Caulfield's osmictetroxide solution, and embedded in methacrylate-styrene (Kushida, 1963). Sections were stained withuranyl acetate and lead citrate and examined in theelectron microscope. Sections were also cut for con-ventional histology after freezing for fat stains, or, afterembedding in paraffin wax, were stained with haema-toxylin and eosin for reticulin.

RESULTS The biopsy specimens were found tocontain several areas of necrosis approximately 1 mmdiameter (Fig. 1). The surviving liver cells showedcloudy swelling and, in the frozen sections, manyglobules staining with Scharlach R. Nuclei of someliver cells among those surviving immediatelyaround the areas of necrosis, but not elsewhere,were shrunken and full of eosinophilic material, thechromatin being concentrated around the nuclear

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FIG. 1. Sections of liver biopsy. An area of necrosis inthe lower right hand corner is bounded by a zone ofinfiltration with polymorphonuclear cells and macrophages.x 100; haematoxylin and eosin.

membrane (Fig. 2). Classical intranuclear inclusionsof Cowdry's type A, with a clear space between theinclusions and the nuclear membrane, were not seen.The reticulin framework of the liver was intact bothin the areas of necrosis and in areas of survivingliver cells, suggesting that the necrosis was recent.The areas of necrosis were densely infiltrated withpolymorphonuclear cells, and mononuclear cellswere also fairly numerous.

Sections examined by electron microscopy werefound to contain numerous cells whose cytoplasmcontained many empty spaces, presumably where fatglobules had been dissolved during preparation butwhich were otherwise comparatively normal. Cellswhose cytoplasm was similarly vacuolated but inwhich the mitochondria appeared swollen werealso seen (Fig. 3). Many mitochondria appearedalso to have lost their cristae, or contained smalland irregular cristae (Fig. 4). Dense osmiophilic'myelin type' figures were also found in the cytoplasmof many cells. In some cells the mitochondria wereseen to contain a peculiar dense longitudinal barof osmiophilic material (Fig. 5); no obvious sub-

FIG. 2. Intranuclear inclusions in cells at the margin oftheliver lesion. The chromatin lines the nuclear membrane,and the nuclei are full of eosinophilic material. x 1,500haematoxylin and eosin.

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T. H. Flewett, R. G. F. Parker, and W. M. Philip

FIG. 3. Part of a liver cell. There are large empty spaces left where fat has been dissolved. Mitochondria appearrather swollen, with loss of cristae. Glycogen granules are plentiful. x 26,000; lead citrate.

structure could be detected in these. It did notseem probable that this was a fixation or cuttingartefact because mitochondria not so affectedwere found in the same cells. The laminar or linearcrystalline structures sometimes found in mitochon-dria of normal human liver cells (Mugnaini, 1964)were not seen; the sections were thin enough to haveenabled such structures to be detected.

In all the liver cells not obviously very severelydamaged large numbers of granules presumedto be glycogen were found in the cytoplasm(Fig. 5).

Prolonxged searching was required to find cellscontaining particles identifiable as herpes-typeviruses. These cells were found to be shrunken,with dense cytoplasm (Fig. 6). The nuclei containeduniformly finely fibrous or granular material, inwhich were embedded virus elementary bodies-

the 'single-membrane' type of particle usually foundin herpes-infected nuclei (Fig. 7). The oval shapeseen in the micrograph is an artefact caused by com-pression during cutting of the sections.No virus particles of the 'double-membrane'

type could be found in the cytoplasm of the infectedcells.

VIROLOGICAL INVESTIGATIONS

METHOD Smears of scrapings taken from the base ofulcers, left where vesicles in the mouth had ruptured,were stained by haematoxylin and eosin. NumerousTsanck cells characteristic of infection by viruses of theherpes group were found.

Scrapings from mouth lesions, homogenized fragmentsof liver biopsy, and blood (both as homogenized clot andserum) were inoculated into tissue cultures of humanamnion, human fibroblasts, HeLa cells, and monkey

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FIG. 4. Cytoplasm of a liver cell showing loss of cristae in mitochondria. An inflammatory cell is seen in contactwith it. x 15,600; lead citrate.

kidney, and on to the chorioallantoic membranes of12-day chick embryos.

RESULTS Herpes simplex virus was isolated with easefrom the scrapings from the mouth lesions, causingconfluent pocks to appear on the chorioallantoicmembranes. Herpes virus was also isolated fromhomogenized liver biopsy in human amnion culturesbut not in monkey kidney, HeLa or human fibro-blast cultures; no virus could be isolated fromwhole blood, buffy coat, serum, or cerebrospinalfluid.One sample of serum taken the day after admission

contained no detectable complement-fixing orneutralizing antibodies for Herpes simplex virus.Serum taken 14 days after admission had a comple-ment-fixation titre of 1: 64 and a neutralizing titre of1:8 against 100 pock-forming units of Herpes

simplex virus; serum taken five months after ad-mission had a complement-fixation titre of 1:256and a neutralizing titre of 1:256 against 100 TCD50of Herpes simplex virus, and produced four linesof precipitation against herpes virus antigens on agel diffusion plate; these lines gave a reaction ofidentity with similar lines produced by the sameantigen with a rabbit hyperimmune serum. (We areindebted to Dr D. H. Watson for performing thegel diffusion test.)

DISCUSSION

Generalized visceral Herpes simplex infection ofneonates is familiar to most pathologists. Themultiple focal necroses of the liver found in in-fection at this age have however rarely been foundin older children, and then have been reported only

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FIG. 5. Mitochondria containing dense inclusions. x 30,000; lead citrate.

in cases of eczema herpeticum (at the age of 1 year)or in cases of malignant malnutrition (kwashiorkor)up to the age of 3, or perhaps 6, years. We havebeen unable to find any published reference to dis-seminated multifocal Herpes simplex hepatitis in anadult. The appearance of the condition in childrensuffering from kwashiorkor suggests that somepreexisting biochemical disorder or deficiency makesthe liver more susceptible to herpes virus infection.

In our patient three factors all tending to liverdamage were present: (1) hyperemesis gravidarum,(2) tetracycline therapy, and (3) Stelazine therapy.The first is a well known cause of liver failure and

needs no discussion. Tetracycline is well known as acause of liver damage and jaundice when givenparenterally, especially in pregnancy, though it isusually regarded as safe in this respect when given

by mouth (Dowling and Lepper, 1964; Kunelis,Peters, and Edmondson, 1965; Schultz, Adamson,Workman, and Norman, 1963). In combination withthe other stresses it may nevertheless have made itscontribution to liver susceptibility even thoughgiven orally to this patient. Cases ofjaundice associ-ated with the administration of Stelazine have beenrarely reported (Kohn and Myerson, 1961) but theremarks about tetracycline are perhaps applicablehere also.The evidence for the herpetic aetiology of the

liver lesions is: 1 The histological nature of thelesions, which resembled those of-neonatal herpetichepatitis both in their size and distribution, andalso in the presence of inclusions in the cells aroundareas of necrosis. 2 The findings by electron micro-scopy of particles morphologically indistinguishable

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FIG. 6. Dense, shrunken virus-infected cell. x 27,500; lead citrate.

from Herpes simplex virus in the nuclei of liver cells,and the presence within the nuclei of the changesassociated with herpes virus infection. 3 Theisolation of Herpes simplex virus from the liverbiopsy. In primary Herpes simplex virus infectionviraemia occurs, and it might be argued that the livercontained some blood and thus might contain virus;but attempts at isolation of herpes virus from bloodtaken at the same time as the liver biopsy wereunsuccessful, although the volume inoculated wasmuch greater than could have been present in thebiopsy. The tissue, therefore, presumably did containviable virus.

In infants dying of generalized visceral herpesinfection, necrotic foci are usually found in thebrain as well as in the abdominal viscera. Althoughwe have no direct evidence of herpetic encephalitisin this patient (attempts to isolate virus fromcerebrospinal fluid were unsuccessful) her degreeof stupor on and shortly after admission seemed outof proportion to the extent of the biochemicalderangement. Electroencephalographic examinationin convalescence showed some abnormality but didnot afford conclusive evidence of encephalitis. Theevidence of viral encephalitic infection is thereforeinsufficient to establish that this probably occurred.

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FIG. 7. Herpes-type particles within the nucleus of an infected liver cell. x 90,700; lead citrate.

REFERENCES Kohn, N., and Myerson, R. M. (1961). New Engl. J. Med., 264, 549.Kunelis, C. J., Peters, J. L., and Edmondson, H. A. (1965). Amer. J.

Becker, W., Naude, W. du T., Kipps, A., and McKenzie, D. (1963). Med., 38, 359.S. Afr. med. J., 37, 74. Kushida, M. (1963). J. electron Microsc., 11, 72.

Dowling, H. F., and Lepper, M. H. (1964). J. Amer. med. Ass., 188, Mugnaini, E. (1964). J. Uttrastruct. Res., 11, 525.307. Schultz, J. C., Adamson, J. S., Jr, Workman, W. W., and Norman,

Kipps, A., Becker, W., Wainwright, J., and McKenzie, D. (1967). T. D. (1963). New Engi. J. Med., 269, 999.S. Afr. med. J., 41, 647.

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