Disseminated herpes simplex virus 2 (HSV-2) encephalitis in a liver transplant recipient: Potential implications for liver transplant programs

Herpes simplex virus type 2 (HSV-2) is a rare cause of herpes encephalitis. We report a case of severe right limbic encephalitis presenting as an altered level of consciousness in a post-liver transplant adult man. HSV-2 was identified by polymerase chain reaction in the cerebrospinal fluid (CSF). Concurrent active perineal skin eruptions were positive for HSV-2, confirming the theory of disseminated HSV-2 from genitals to brain. Intravenous acyclovir was given for 3 weeks. Although the outcome was an improved level of consciousness, the patient was left with significant residual neurological morbidity. Our experience emphasizes the importance of HSV prophylaxis in those with positive serostatus pre-transplant, and not on cytomegalovirus (CMV) prophylaxis in the immediate post-transplant period. We also recommend stringent pre-transplant assessment, including specific and direct questioning of candidates regarding a history of sexually transmitted infections (STIs), a determination of HSV serostatus, and the examination and testing of any suspicious lesions.