Laparoscopic Liver Biopsy – Essential for Diagnosing Herpes Hepatitis

Heidi Miller, MD, Jay J Strain, MD, Jihan Hegazy, MD, Sarah Perloff, DO, Amit R Joshi, MD

Albert Einstein Healthcare Network

Introduction. Herpes Simplex Hepatitis is a rare and severe disease. It has a nonspecific clinical picture and is difficult to diagnose. On imaging it often appears similar to bacterial infection and tissue biopsy is necessary for diagnosis. The severity of the disease varies and the mortality ranges from 50 – 100%. However, treatment with IV acyclovir can be very effective.

Case Report. A 28-year old female presented with right upper quadrant pain, vomiting, and fevers. She underwent ultrasound imaging, revealing only gallbladder sludge. Her liver function tests were normal. She continued to have right upper quadrant tenderness and underwent laparoscopic cholecystectomy. Intraoperative findings included an edematous gallbladder and inflammatory adhesions. The gallbladder histology revealed chronic acalculous cholecystitis. Postoperatively the patient had increasing total bilirubin and transaminases and continued to have persistent fevers and pain. An extensive evaluation revealed no anatomic abnormalities, but with ongoing fevers and transaminitis, she was extensively cultured and tested, and was diagnosed with Human Immunodeficieny Virus (HIV). A percutaneous liver biopsy was negative for any etiology, and finally a laparoscopic liver wedge resection revealed Herpes Simplex 2 Virus (HSV) hepatitis, for which treatment was initiated.

Discussion. The diagnosis of HSV hepatitis is quite challenging. It typically manifests as anicteric hepatitis, and because of its acute inflammatory effect on the liver, can mimic cholecystitis. Delayed diagnosis without antiviral therapy significantly contributes to the guarded prognosis with a high mortality. Liver biopsy is necessary for diagnosis, and laparoscopic liver biopsy has the advantage of harvesting a large specimen for histologic, immunologic, viral, and bacterial analysis. This may aid in earlier diagnosis and thus earlier treatment to provide patients with improved outcomes.

Session: Poster Presentation

Program Number: P352

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