Herpes Simplex Virus Type 2 (HSV-2) Infection

Case Presentation

A seventy-year-old African American female with a past medical history of essential hypertension, type two diabetes mellitus, gout, and osteoarthritis presented to the hospital with complaints of pruritic skin rash around the eyes, diarrhea, and weakness. The patient was started on allopurinol a few weeks prior to presentation after an acute gout flare in the right foot. Patient had an oral temperature of 103 ˝F, a maculopapular rash of the face, eyelids, torso, and extremities, and diffuse tenderness with palpation of the abdomen.

An esophagogastroduodenoscopy revealed reflux esophagitis and an erythematous duodenum (Figure 1). A colonoscopy showed congested mucosa in the ascending colon and diverticulosis in the sigmoid and descending colon (Figure 2). The histopathology of colon biopsies revealed extensive crypt dropout and crypt epithelial apoptosis, suggestive of a drug reaction. The viral immunostains were negative.

Figure 1: Initial Lower Endoscopy

The patient was diagnosed with DRESS syndrome and autoimmune hemolytic anemia secondary to allopurinol. She was started on IV solumedrol and topical triamcinolone cream. On day ten of admission, the patient became hypotensive with a blood pressure of 79/61 mmHg and was complaining of persistent diarrhea. A computed tomography (CT) scan of the abdomen and pelvis showed severe dilatation of the small bowel, suggestive of severe ileus, and free fluid surrounding the liver and spleen.

Figure 2: Initial Lower Endoscopy.

A repeat colonoscopy reported evidence of segmental ischemic colitis in the descending and sigmoid colon as well as erythema and punctate hemorrhage in the rest of the colon, with suspicion of small bowel involvement (Figure 3).

Figure 3: Segmental ischemic colitis in the descending and sigmoid colon

Figure 4: Ongoing Ischemic changes in Right Colon and Descending Colon.

Discussion

This is a case of a patient with HSV-2 infection presenting with toxic megacolon, ischemic colitis, and necroinflammation of the liver in the absence of transaminitis. Classically, HSV tends to infect squamous epithelial cells rather than columnar epithelial cells. In the literature review, disseminated gastrointestinal HSV infection can occur in immunocompromised hosts, particularly those on steroids or in IBD patients treated with immunomodulators [1–3]. Cytomegalovirus has been described to cause toxic megacolon and ischemic colitis in patients with underlying IBD [2–3]. HSV is known to cause mucocutaneous ulcerations and esophagitis when reactivated in immunocompromised hosts, but it does not typically cause ischemic colitis [4]. There are rare case reports of HSV causing ischemic colitis in patients with IBD on immunomodulators [2–3]. This patient was different than other prior case reports of HSV causing ischemic colitis because she was not on any immunomodulators. This is also the first known reported case of HSV causing toxic megacolon. In patients who present with fulminant HSV hepatitis, one of the hallmark signs is markedly elevated transaminases. This patient was noted to have visible intraoperative nodular changes to her liver, and a liver biopsy showed necroinflammation secondary to HSV despite the normal aspartate aminotransferase and alanine transaminase at the time of her surgery. To our knowledge, this is the first case of a patient presenting with toxic megacolon, ischemic colitis, and hepatitis (in the absence of transaminitis) secondary to disseminated HSV-2 following steroid use

Funding

This research received no external funding.

Conflicts of Interest