Case Report
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Feb 16, 2018; 6(2): 11-19
Published online Feb 16, 2018. doi: 10.12998/wjcc.v6.i2.11
Fatal fulminant herpes simplex hepatitis following surgery in an adult
Yoshihiro Yokoi, Takeshi Kaneko, Tomoki Sawayanagi, Yasuo Takano, Yoichi Watahiki
Yoshihiro Yokoi, Takeshi Kaneko, Tomoki Sawayanagi, Youichi Watahiki, Department of Surgery, Shinshiro Municipal Hospital, Shinshiro 441-1387, Japan
Yasuo Takano, Department of Pathology, Shinshiro Municipal Hospital, Shinshiro 441-1387, Japan
Author contributions: Yokoi Y, Kaneko T, Sawayanagi T and Watahiki Y participated in the diagnosis and management of this case; Takano Y provided a critical and valuable discussion on the histopathologic study.
Informed consent statement: Informed consent to publish was obtained from the family of the patient.
Conflict-of-interest statement: The authors state that they have no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Yoshihiro Yokoi, MD, Doctor, Department of Surgery, Shinshiro Municipal Hospital, 32-1 Kitahata, Shinshiro 441-1387, Japan.
Telephone: +81-536-222171 Fax: +81-536-222850
Received: November 4, 2017
Peer-review started: November 4, 2017
First decision: November 30, 2017
Revised: December 15, 2017
Accepted: January 16, 2018
Article in press: January 16, 2018
Published online: February 16, 2018
Case characteristics

A healthy 72-year-old man developed fatal herpes simplex hepatitis soon after ordinary surgery for biliary stones.

Clinical diagnosis

A sudden onset of hepatitis associated with high fever and leukopenia emerged on postoperative day 5, followed by a rapid and lethal course (died on day 9).

Differential diagnosis

Several factors specific for postsurgical condition including hemodynamic changes, hepatotoxic drugs, anesthesia, and septic infection make complicated in differential diagnosis of postoperative hepatitis.

Laboratory diagnosis

A rapid elevation of liver aminotransferases (aspartate aminotransferase > alanine aminotransferase) without alteration of cholestasis was followed by coagulation disorder and encephalopathy.

Imaging diagnosis

A contrast-enhanced computed tomography showed heterogeous contrast distribution and a mottled liver without any abscess formation.

Pathological diagnosis

Postmortem liver biopsy revealed diffuse necrosis and loss of normal architecture with characteristic findings of intranuclear inclusions.


Empiric therapy with acyclovir, intravenous injection (10 mg/kg, every eight hours) was initiated on postoperative day 8.

Related reports

Fatal herpetic hepatitis occurs in non-surgical healthy adults as well, whereas the disease following surgery is rarer and is more difficult for precise diagnosis.

Term explanation

Development of herpetic hepatitis is fatal complication following surgery, because of the difficulty for precise diagnosis and rapid deterioration of the disease.

Experiences and lessons

Due to the difficulty in diagnosis and lethal nature, an early clinical suspension and prompt empirical anti-viral intervention are imperative for postsurgical hepatitis with undetermined etiology, characterized by fever and leucopenia.