Febrile illness in pregnancy: disseminated herpes simplex virus.

Awoman at 26 weeks of gestation presented with 2 days of nausea, vomiting, fevers, and abdominal pain. She had no recent travel or sick contacts. Her medical history was significant for gonorrhea and cholecystectomy. On physical examination her temperature was 38.5 ̊C and she had right abdominal tenderness with a normal pelvic examination and no signs of preterm labor. The nonstress test was reactive. Initial laboratory evaluation revealed a leukocytosis of 15.83109/L with left shift, normal hemolysis, elevated liver enzymes, and low platelet count laboratory results, negative gonorrhea and chlamydia tests, and urinalysis. A wet mount was positive for Trichomonas infection. Given the severe pain, a magnetic resonance image of the abdomen and pelvis was ordered and preliminary reading was negative for appendicitis. After observation and treatment with metronidazole and acetaminophen, she improved and was discharged home. The next day, she returned with fevers of up to 39.4 ̊ C and abdominal pain with rebound and guarding. The leukocytosis had resolved, but a nonstress test revealed a fetal heart rate in the 170s. Broad-spectrum antibiotics were started. The prior day’s magnetic resonance image final read did not identify the appendix but showed right ovarian compression and enlargement of the right uterine vessels. Given the significant fundal tenderness, an amniocentesis was performed with initial results being inconsistent with infection. Final cultures were subsequently negative. With worsening right abdominal pain, a surgeon was consulted who recommended exploratory laparotomy. An appendectomy was performed, and both general surgeons and obstetrician–gynecologists confirmed normal bilateral adnexa. The pathology findings were not consistent with appendicitis. Through hospital day 4, the negative laboratory work-up included: amniotic fluid, blood, and urine cultures, rapid plasma reagin, human immunodeficiency virus AG/AB, cytomegalovirus immunoglobulin (Ig)M/ IgG, herpes simplex virus (HSV) IgG, hepatitis A/B/C serologies, and tests for influenza A/B/H1N1, mycoplasma, ureaplasma, toxoplasmosis, parvovirus, tuberculosis, ehrlichiosis, Rocky Mountain spotted fever, and lyme disease. The echocardiogram and chest radiograph results were negative. At the recommendation of an infectious disease consultant, her antimicrobials were broadened from ampicillin and gentamicin and metronidazole to piperacillin and tazobactam and vancomycin. She received heparin for potential septic thrombophlebitis. She remained febrile to greater than 40.0 ̊C with persistent fetal tachycardia. On hospital day 4, while obtaining a urine specimen, the nurse observed a solitary 1-cm painless ulcer on the labium. Tests from the lesion revealed HSV-2 DNA. Intravenous acyclovir was initiated, and she became afebrile within 12 hours. Herpes simplex virus-2 DNA from her blood confirmed dissemination. Outpatient acyclovir prophylaxis was continued. However, at 37 weeks of gestation, three painless labial lesions were found to be HSV-2 polymerase chain reaction-positive and she presented in labor at 38 weeks of gestation and was delivered by cesarean. Her neonate was healthy and without evidence of HSV infection. A representative HSV lesion is shown in Figure 1.