Fulminant herpes hepatitis in an immunocompetent pregnant woman: CT imaging features K. J. Mortele ´ , M. A. Barish, K. E. Yucel Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA Abstract Fulminant hepatitis due to herpes simplex virus (HSV) is rare in immunocompetent adults. Most reported cases have clearly established pregnancy as a condition that can predis- pose to disseminated HSV infection. We report a case of a 25-year-old previously healthy pregnant woman who pre- sented with fatigue, fever, and anicteric hepatitis. Triphasic contrast-enhanced computed tomography demonstrated a miliary pattern of multiple, hypovascular, subcentimeter le- sions scattered throughout the liver. Familiarity with the clinical findings and computed tomographic appearance may prompt early recognition of fulminant HSV hepatitis and allow differentiation from other hepatic disease during preg- nancy. Key words: Liver—infection—Computed tomography— Herpes simplex virus—Pregnancy Liver disease occurring in pregnancy can be categorized into three groups [1]. The first group includes diseases unique to pregnancy and those caused by it. Among these are intrahe- patic cholestasis of pregnancy, acute fatty liver of preg- nancy, and preeclampsia disorders [1]. The second group of liver diseases includes those exacerbated by pregnancy: usu- ally benign viral infections involving the liver, such as herpes simplex and hepatitis E [1]. The third group is com- prised of liver diseases existing before pregnancy. The third group is small because chronic liver disease is rare in women of childbearing age [1]. Since 1967, approximately 40 clinical cases of herpes simplex virus (HSV) hepatitis have been reported, but none in the radiologic literature [2, 3]. Clinically, mucocutaneous lesions are present in only 50% of cases, so diagnosis of this disease is typically low [2]. The differential computed to- mographic (CT) diagnosis of a miliary distribution of hy- poattenuating micronodules in the liver in a pregnant woman includes fungal, bacterial, and viral microabscesses and pre- existing liver disease such as sarcoidosis; this imaging ap- pearance allows differentiation from disorders associated with preeclampsia [4]. Familiarity with the clinical findings and CT appearance may prompt early recognition of fulminant herpes hepatitis and allow differentiation from other hepatic disease during pregnancy in a timely fashion. Case report A 25-year-old immunocompetent woman, who was 34 weeks pregnant, presented to an outside hospital with a 3-week history of progressive fatigue and fever. On labora- tory examination, she was found to have significantly ele- vated liver function tests. She was transferred to our institution, where an urgent caesarean section was performed to preserve the life of her 34-week son. Further evaluation for her hepatitis confirmed the presence of anicteric fulmi- nant hepatitis (alanine aminotransferase, 980 U/L [normal range, 7–52]; aspartate aminotransferase, 2240 U/L [normal range, 9 –30]; alkaline phosphatase (ALK), 216 U/L [normal range, 36 –118]; total bilirubin (BILT), 0.6 mol/L [normal range, 0.2–1.2]) and abnormal coagulation (prothrombin time, 16.0 [normal range, 12.5–14.5]; partial thromboplastin time, 44.2 [normal range, 23.8 –36.6]; international normal- ized ratio of prothrombin time, 1.3 [normal range, 0.9 –1.1]; platelet count, 83  10 9 /L [normal range, 150 – 450]). A subsequent abdominal triphasic contrast-enhanced CT scan, obtained 1 day after delivery, demonstrated a miliary distribution of subcentimeter, hypoattenuating lesions scat- tered throughout all liver segments (Fig. 1). A normal post- pregnancy uterus was seen in the pelvis. The presumptive differential CT diagnosis included fungal, bacterial, and viral microabscesses and preexisting unknown liver disease such Correspondence to: K. J. Mortele ´; email: kmortele@partners.org Abdominal Imaging © Springer Science+Business Media, Inc., 2004 Received: 29 December 2003 / Accepted: 11 February 2004 / Published online: 3 June 2004 Abdom Imaging (2004) 29:682– 684 DOI: 10.1007/s00261-004-0199-y