Hofer, S.

Hunziker, S.

Ludwig, C. U.

Tornillo, L.

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Annals of Oncology 14: 340, 2003Letters to the Editor© 2003 European Society for Medical OncologyFatal herpes simplex virus hepatitis complicating chemotherapy with weekly docetaxelWe report a 50-year-old female patient who was diagnosed withmetastatic breast cancer 3.5 years ago. Her most recent treatmentfor liver and lymph node metastases was docetaxel given on aweekly schedule. Standard prophylaxis with dexamethasone priorto each docetaxel infusion was given. After a 6-week course, acomputed tomography (CT) scan revealed partial remission ofthe liver and lymph node metastases. Therapy was resumed aftera 3-week interval. The patient was hospitalized with a decreasedperformance status (suffering from nausea and vomiting) 72 hafter administration of dexamethasone and docetaxel. Laboratoryanalysis showed an anicteric hepatitis with pronounced elevationof serum aminotransferases (aspartate aminotransferase 3283 U/l,alanine aminotransferase 1987 U/l), but normal bilirubin andleukopenia (0.6 × 109/l). No mucocutaneous lesions, typicallysuggestive of herpes simplex virus (HSV) infection, were detect-able. Despite intensive supportive care the patient died offulminant liver failure on the fifth day after chemotherapy. Aliver biopsy taken immediately post mortem disclosed the strik-ing pathological finding of non-inflammatory liver necrosis withclassical features of internuclear eosinophilic inclusion bodies,and a homogeneous immunohistochemical staining for HSV.Herpes simplex virus-induced hepatitis is a rare infection inimmunocompetent adults, but patients with impaired cellularimmunity may be at risk. HSV hepatitis often presents as afulminant disease that is usually fatal (>80%). Clinical featuresinclude fever, anorexia with nausea and/or vomiting, abdominalpain, leukopenia, coagulopathy and elevation of serum amino-transferases without jaundice. Characteristic oral and/or genitallesions occur in only 30% of cases [1, 2]. To our knowledge, therehave been no previous reports of fatal HSV hepatitis complicat-ing chemotherapy with weekly low-dose docetaxel treatment incombination with dexamethasone. However, infection may gounnoticed, even post mortem, due to rapid autolysis of the livertissue.As potentially effective treatment for HSV infection is avail-able (acyclovir), we suggest transjugular liver biopsy as a safediagnostic procedure in cases of rapid performance statusdeterioration and pronounced liver enzyme elevation in patientsundergoing chemotherapy. Serum HSV DNA detection might beof false positive significance due to irrelevant former exposure tothe virus [3].S. Hofer1*, S. Hunziker1, L. Tornillo2 & C. U. Ludwig11Medical Department, St. Claraspital, Basel; 2Institute of Pathology, University Hospitals Basel, Switzerland (*E-mail: silviahofer@hotmail.com)References1. Farr RW, Short S, Weissmann D. Fulminant hepatitis during herpes sim-plex virus infection in apparently immunocompetent adults: report oftwo cases and review of the literature. Clin Infect Dis 1997; 24: 1191–1194.2. Fahy RJ, Crouser E, Pacht ER. Herpes simpex type 2 causing fulminanthepatic failure. South Med J 2000; 93: 1212–1216.3. Peters DJ, Greene WH, Ruggiero F, McGarrity TJ. Herpes simplex-induced fulminant hepatitis in adults: a call for empiric therapy. Dig DisSci 2000; 45: 2399–2404.DOI: 10.1093/annonc/mdg052

Fatal herpes simplex virus hepatitis complicating chemotherapy with weekly docetaxel

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