Take-home pearl (thanks Jen!): pregnancy is a relatively immunocompromised state. In the post-partum period, think about immune reconstitution syndrome! See the attached CID review article from Jen on this! Also here: http://www.ncbi.nlm.nih.gov/pubmed/17918082
And one other take-home pearl (thanks Harry!): +HSV PCR in CSF in the absence of inflammatory CSF makes the diagnosis of HSV meningitis unlikely!
Liver disease in pregnancy: see attached article from Hepatology 2008! Also here: http://www.ncbi.nlm.nih.gov/pubmed/18265410
- Great table from the article below. One approach to thinking about liver disease in pregnancy is: 1) is it coincidental to pregnancy? 2) Underlying liver disease? 3) Unique to pregnancy?
- A bit more on HELLP (hemolysis, elevated liver enzymes, low platelets):
- A complication of severe preeclampsia
- Often in multiparous women
- Often have HA, RUQ pain, n/v
- Treatment = immediate deliver, high dose magnesium
- Course: Most patients have rapid, early resolution of HELLP after delivery with normalization of platelets by 5 days.
- Persistence beyond this is an indication fo specific treatment – eg plasmapheresis, antithrombotic agents, steroids, plasma exchange with FFP (though none have clinical trial data)
- Complications include DIC, seizures, ARF, ARDS, severe ascites, liver failure, liver rupture (!)
- A bit more on acute fatty liver of pregnancy
- Microvesicular fatty infiltration – can range from asymptomatic to fulminant liver failure!
- High perinatal and maternal mortality, requires early dx and tx!
- Often in nulliparous women, with increased risk in twin pregnancies
- Similar sxs to HELLP, can also have jaundice. There is some overlap with HELLP.
- AST/ALT usually 300-500 range but can vary from near normal to 1000! Also see normocytic anemia, high WBC, nl/low plts, coagulopathy, acidosis, hypoglycemia, hyperammonemia
- Treatment = immediate delivery (there are no reports of recovery before delivery!), intensive supportive care
- Course: Most patients improve by 2-3d after delivery, though can take 1-4 weeks to fully resolve
- Lastly, a note on HSV and acute liver failure – some good articles on pubmed on this, esp reported in pregnant women! Here is one review article on HSV sepsis and ALF: http://www.ncbi.nlm.nih.gov/pubmed/19930315 (attached)
- At risk populations: patients on immunosuppressive meds (chemo, post-transplant), HIV, pregnancy esp in 3rd trimester
- severe clinical course, mortality up to 75%
- Accounts for 1% of all ALF
- Start empiric ACV in ALF of unknown etiology!
See this old blog post about HLH!
And this one on acute liver failure