RESUMO
A young woman presented with a febrile illness in the third trimester of pregnancy. Laboratory investigation revealed severe acute hepatitis with thrombocytopenia and coagulopathy. Liver injury progressed despite emergent caesarian section and delivery of a healthy infant. Therefore, therapeutic plasma exchange (TPE) was performed on three consecutive days post-partum for a presumed diagnosis of acute liver failure (ALF) associated with pregnancy due to hemolysis, elevated liver enzymes, and low platelets (HELLP) or acute fatty liver of pregnancy (AFLP). Treatment with TPE was followed by biochemical and clinical improvement but during her recovery herpes simplex virus type 2 (HSV-2) infection was diagnosed serologically and confirmed histologically. Changes in the immune system during pregnancy make pregnant patients more susceptible to acute HSV hepatitis, HSV-related ALF, and death. The disease is characterized by massive hepatic inflammation with hepatocyte necrosis, mediated by both direct viral cytotoxicity and the innate humoral immune response. TPE may have a therapeutic role in acute inflammatory disorders such as HSV hepatitis by reducing viral load and attenuating systemic inflammation and liver cell injury. Further investigation is needed to clarify this potential effect. The roles of vigilance, clinical suspicion, and currently accepted therapies are emphasized.
Assuntos
Hepatite Viral Humana/complicações , Herpes Simples/complicações , Falência Hepática/etiologia , Troca Plasmática , Complicações na Gravidez/etiologia , Doença Aguda , Aciclovir/uso terapêutico , Antibacterianos/uso terapêutico , Antivirais/uso terapêutico , Cesárea , Terapia Combinada , Dexametasona/uso terapêutico , Emergências , Feminino , Maturidade dos Órgãos Fetais , Hepatite Viral Humana/tratamento farmacológico , Hepatite Viral Humana/terapia , Herpes Simples/tratamento farmacológico , Herpes Simples/terapia , Humanos , Hidrocortisona/uso terapêutico , Recém-Nascido , Falência Hepática/terapia , Masculino , Gravidez , Complicações Infecciosas na Gravidez , Transtornos Puerperais/tratamento farmacológico , Transtornos Puerperais/terapia , Síndrome de Resposta Inflamatória Sistêmica/tratamento farmacológico , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Síndrome de Resposta Inflamatória Sistêmica/terapia , Adulto JovemRESUMO
We describe a 45-year-old woman receiving infliximab therapy for rheumatoid arthritis who developed an overwhelming Plasmodium falciparum infection with cerebral malaria. Physicians should be aware that patients receiving tumor necrosis factor inhibitors, such as infliximab, may be at increased risk of life-threatening malarial infections.