Disseminated Herpes Simplex Virus Presenting as Postpartum Sepsis: A Rural Case Report

Disseminated Herpes Simplex Virus Presenting as Postpartum Sepsis: A Rural Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Disseminated Herpes Simplex Virus Presenting as Postpartum Sepsis: A Rural Case Report Raeghan O’Leary, Jaskaranvir Singh-Ranger, Gurpreet Singh-Ranger This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9130561/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Infection with disseminated herpes simplex virus (HSV) in pregnancy and the postpartum period can be a potentially devastating condition. Postpartum presentations may mimic bacterial sepsis and frequently present without mucocutaneous lesions, which can delay diagnosis and treatment. The purpose of this report is to highlight the diagnostic challenges of disseminated HSV presenting as postpartum sepsis and to emphasize the importance of early empiric antiviral therapy, especially at rural sites where rapid polymerase chain reaction (PCR) testing is not available. Methods We present the case of a 23 year old woman at 39 weeks’ gestation (gravida 4, para 0, abortus 3) who delivered a female infant via caesarean section. They were discharged from the hospital after 72 hours with no health concerns. Four days post-operatively, the patient re-presented and was admitted due to fever, exertional dyspnea, pleuritic chest pain, and generalized myalgia. Laboratory results and clinical observations were suggestive of septic shock, and intravenous (IV) antibiotics were started. Results Despite broad-spectrum antibiotic therapy, the patient remained unwell. On post-admission day 2, she disclosed a recent history of genital herpes infection several weeks prior to her caesarean section. IV acyclovir was started immediately, as our rural facility does not have access to on-site HSV PCR testing. Clinical improvement followed and vesicular lesions later developed near the caesarean site, supporting the diagnosis of disseminated HSV. The neonate remained asymptomatic through the clinical course. Conclusion This case illustrates the diagnostic uncertainty that may arise when disseminated HSV presents as postpartum sepsis. Clinicians should maintain a high index of suspicion for HSV infection in postpartum patients who fail to respond to antibiotic therapy, as early empiric antiviral treatment may significantly influence patient outcomes. Herpes simplex virus caesarean section acyclovir postpartum sepsis case report Figures Figure 1 Figure 2 Introduction Infection with herpes simplex virus (HSV) is relatively common in North America and usually is a localized, self-limiting condition. Approximately 12% of individuals aged 14–49 years in the United States are seropositive for HSV-2, which traditionally has been the main cause of genital herpes 1 . However, in the last decade, there has been an increasing number of genital infections due to the HSV-1 virus, which is the most common cause of oral herpes 2 , 3 . HSV incidence is highest in women of reproductive age; therefore, the risk of maternal transmission to fetuses and neonates is a major health concern 3 . Disseminated HSV infection is a rare but life-threatening complication, particularly in pregnancy and the postpartum period 4 , 5 . It is associated with high maternal and neonatal mortality and can present with nonspecific features 4 . Approximately 20–25% of women in pregnancy are seropositive for HSV-2, and approximately 2–3% of seronegative women will acquire a primary HSV infection during pregnancy 6 , 7 . A systematic review of 114 published cases over a 60-year period found that presenting symptoms of disseminated HSV included altered liver function, gastrointestinal symptoms, respiratory challenges, fever, and neuropsychiatric symptoms, and most did not have mucocutaneous lesions at presentation 4 . Therefore, disseminated HSV infection may mimic bacterial sepsis, HELLP syndrome, or acute fatty liver of pregnancy and often has a late diagnosis, leading to a delay in appropriate treatment 4 , 5 , 8 . Early recognition of disseminated HSV is critical, and maternal survival has been shown to be significantly higher among those who are treated with acyclovir than those who are not 4 . In 2018, coroner’s reports from the United Kingdom described two fatal cases of disseminated HSV infection shortly after cesarean section at the same hospital, within weeks of each other 9 . Both cases presented with suspected bacterial sepsis and did not respond to antibiotics 9 . Unfortunately, antiviral treatment was initiated too late in the disease course, and both patients died 9 . Despite the high morbidity and mortality associated with disseminated HSV in pregnancy and the postpartum period, it is not consistently addressed in sepsis guidelines 4 . HSV is acknowledged in obstetric-specific guidelines, but these resources are often not accessed until after HSV is clinically considered and suspected 4 . Therefore, guidelines in emergency and acute care settings may not prompt clinicians to consider disseminated HSV, especially in the absence of mucocutaneous lesions 4 . This gap has been recently highlighted in the literature, emphasizing that disseminated HSV frequently presents with non-specific features and may be misdiagnosed as bacterial sepsis, resulting in delayed antiviral therapy and preventable mortality. We report a case of disseminated HSV that presented 4 days after an uncomplicated caesarean section, manifesting as severe sepsis unresponsive to broad-spectrum antibiotics. This case highlights the diagnostic challenges of disseminated HSV in the postpartum period and the importance of early empiric antiviral therapy, especially in rural settings where confirmatory testing is not immediately available. Case Report A 23-year-old 39-week pregnant woman (gravida 4, para 0, abortus 3) presented in labour to our rural facility in May 2023. An emergency caesarean section was called by the family physician managing the labour due to non-reassuring fetal heart rate tracing. The procedure was uncomplicated, with minimal blood loss, and a healthy female infant weighing 3660g was delivered. Post-operatively, the patient's condition was unremarkable, and they were discharged home 72 hours after delivery. Twenty-four hours following discharge (post-operative day 4), the patient re-presented with fever, exertional dyspnea, pleuritic chest pain, and generalized myalgia. Her temperature was 38.3°C, blood pressure 98/56 mmHg, heart rate 125 beats/min, and oxygen saturation 96% on 2 L/min supplemental oxygen. She was anxious, but alert and oriented. Non-pitting peripheral edema was present, and respiratory examination demonstrated decreased breath sounds bilaterally. Given concern for pulmonary embolism, urgent computed tomography (CT) pulmonary angiography was performed, which demonstrated a small right pleural effusion and basal atelectasis, the latter also seen on chest radiograph (Figs. 1 and 2 ). There was no evidence of pulmonary emboli. CT abdomen and pelvis were unremarkable. The small pleural effusion was not considered clinically significant. Examination of the caesarean section wound revealed mild operative tenderness without erythema, discharge, or cutaneous lesions. Laboratory investigations demonstrated leukocytosis, markedly elevated C-reactive protein, and elevated alkaline phosphatase, with normal amylase, creatine kinase, and troponin levels (Table 1 ). In the absence of an alternative diagnosis, sepsis with evolving shock physiology was suspected based on her inflammatory markers, hypotension, tachycardia, and respiratory symptoms. The patient was admitted and started on intravenous piperacillin–tazobactam (4.5g every 6 hours) and intravenous fluid resuscitation. Blood, urine, and sputum cultures were negative. Despite broad-spectrum antibiotic therapy, she experienced worsening dyspnea, chest pain, peripheral edema, persistent pyrexia, and rising inflammatory markers (Table 1 ) over the following 48 hours. An internal medicine consultation was obtained, and diuretic therapy was initiated for suspected cardiac dysfunction. There was no clinical improvement, and on post-admission day 2, further history revealed a prior diagnosis of genital herpes simplex virus infection during pregnancy. At that time, no mucocutaneous lesions were noted on examination. Given the lack of response to antibiotics and the clinical history, empirical intravenous acyclovir therapy was started. The patient demonstrated rapid clinical improvement within 48 hours, with resolution of her fever and respiratory symptoms, marked declines in inflammatory markers, and improved liver enzymes (Table 1 ). Blood and urine cultures remained negative, as did screening for methicillin-resistant Staphylococcus aureus , SARS-CoV-2, and influenza. On post-admission day 5, 3 days after initiation of acyclovir, several vesicular lesions consistent with herpes simplex virus infection developed adjacent to the caesarean section wound. HSV polymerase chain reaction (PCR) testing was not available to confirm the diagnosis. The patient completed a 10-day inpatient course and was discharged home on oral acyclovir. At follow-up, 1 week after discharge (Day 21) she remained clinically well. The neonate remained asymptomatic throughout and did not require antiviral therapy. A summary of the clinical course is presented in Table 2 . Table 1 Serial laboratory results during the patient’s clinical course. Day 0 (Admission to facility) 1 2 4 5 8 1 week Post discharge Antimicrobial Therapy IV antibiotics piperacillin tazobactam 4.5g IV acyclovir Oral acyclovir Hb 107 98 103 109 102 109 119 White count 16.8 13.5 12.9 16.5 13.9 16.5 10.5 Platelets 216 254 254 358 332 760 546 Creatinine 75 73 77 72 70 75 - bilirubin 7 8 6 5 7 5 3 ALP 280 282 300 234 280 234 104 ALT 34 28 23 14 10 8 7 CRP 243.8 369.8 432.6 232.6 184.5 107.4 20.6 Table 2 Timeline of clinical course. Time Clinical Event Day 0 Caesarean section performed for non-reassuring fetal heart tracing. Healthy infant delivered. Day 3 Patient and baby discharged home in stable condition. Day 4 Re-presented with fever, dyspnea, pleuritic chest pain, and myalgia. CT pulmonary angiography showed basal atelectasis and small pleural effusion. Patient admitted, and broad-spectrum antibiotics were initiated. Day 6 (Admission Day 2) Persistent fever and worsening inflammatory markers despite antibiotics. History of genital HSV disclosed and IV acyclovir initiated. Day 8 (Admission Day 4) Marked clinical improvement. Inflammatory markers began declining. Day 9 (Admission Day 5) Mucocutaneous vesicular lesions developed near the caesarean section incision site. Day 14 (Admission Day 10) Completed inpatient treatment and discharged home on oral acyclovir. Day 21 (Follow-Up) Patient clinically well. Neonate remained asymptomatic. Discussion Disseminated HSV in pregnancy and postpartum remains a rare, potentially devastating condition. It is more commonly described during pregnancy and often presents with encephalitis, hepatitis, disseminated skin lesions, and disease that also affects the newborn 10 . In a systematic review by Harrison and Clarke, postpartum infections accounted for fewer than 10% of reported cases, with a median presentation at 6 days post-delivery 4 . Our patient re-presented 4 days after an uncomplicated caesarean section with fever, dyspnea, pleuritic chest pain, and laboratory evidence of systemic inflammation with hepatic involvement. As in previously reported cases, examination of her skin did not reveal mucocutaneous lesions, and she was initially managed as presumed bacterial sepsis. Harrison and Clarke emphasize the diagnostic value of speculum examination, noting that 44.4% of genital herpes lesions were confined to the vagina or cervix and would not have been identified without internal examination 4 . Speculum examination was not performed for this patient as she was admitted under general surgery, the responsible service for caesarean sections at our rural facility, and the value that this examination may provide was not appreciated at the time. Departmental practice has been changed subsequently to include speculum examination in all patients presenting with sepsis post-caesarean section. Additional training for staff has also been provided. Mildly abnormal liver enzyme tests were a notable laboratory finding in our patient (Table 1 ). Abnormal liver function during disseminated HSV is common, 4, 10 and hepatic involvement may be present in over 70% of cases 4 . While elevated alkaline phosphatase may be physiological in pregnancy, associated transaminitis should prompt consideration of viral hepatitis, including HSV 4 , 12 . Similar findings have been reported in analyses of HSV hepatitis, where abnormal liver enzymes serve as an early diagnostic clue 13 . Postpartum fever with non-specific symptoms and sepsis unresponsive to antibiotics is a key feature of disseminated HSV infection 4 , 11 . Early empiric treatment with acyclovir is critical. Harrison and Clarke describe a marked difference in maternal survival observed with acyclovir treatment (0.88 vs 0.42), supporting a low threshold for initiating antiviral therapy in a postpartum patient presenting with sepsis refractory to antibiotics 4 . In our case, intravenous acyclovir was started following recognition of antibiotic non-response and history of genital HSV infection, leading to a rapid improvement and clinical diagnosis of disseminated HSV. This was further supported by the subsequent development of vesicular lesions near the caesarean incision site. Rural practice settings contribute to the delayed diagnosis of disseminated HSV. For example, access to rapid HSV diagnostic testing is often limited. Confirmatory PCR testing requires transport to a reference laboratory, and results may take up to two weeks to return to our facility. In suspected disseminated HSV, this delay limits the clinical utility of confirmatory testing for acute management. Another challenge at rural sites may be a lack of specialty coverage, which can lead physicians to practice more generally. A speculum examination may have facilitated earlier recognition, but there was no access to on-site obstetrical consultation. Conclusion Postpartum disseminated HSV diagnosis is complex, as symptoms are non-specific, may mirror other pregnancy or post-operative complications, and patients frequently report no history of HSV 4 , 5 , 11 . Coroner’s reports in the United Kingdom illustrate the fatal nature of disseminated HSV following caesarean section when antiviral therapy is not initiated promptly 9 . Clinicians should maintain a high index of suspicion for disseminated HSV in postpartum patients who fail to respond to standard sepsis management, particularly as HSV is not consistently addressed in general sepsis guidelines. Given acyclovir's safety profile, availability, and potential life-saving benefit 13 – 16 , empiric antiviral therapy should be strongly considered 4 . Early recognition may significantly influence patient outcomes, as delays in treatment may result in significant morbidity and mortality. Declarations Conflicts of interest The authors declare no conflicts of interest. Ethics/Consent for publication Ethical approval was not required for this case report in accordance with institutional policy. Written informed consent was obtained from the patient for publication of this case report and associated images. CARE Statement This case report was prepared in accordance with CARE reporting guidelines, and a CARE checklist has been completed. Funding No funding was received for this work. Author Contribution RO contributed to the literature review, drafting of the manuscript, and preparation of figures and tables. JSR contributed to literature review. GSR contributed to interpretation of the clinical findings. All authors reviewed the manuscript and completed edits. References McQuillan G, Kruszon-Moran D, Flagg EW, Paulose-Ram R. Prevalence of herpes simplex virus type 1 and type 2 in persons aged 14–49: United States, 2015–2016. NCHS Data Brief. 2018;(304):1–8. Xu F, Sternberg MR, Kottiri BJ, McQuillan GM, Lee FK, Nahmias AJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA. 2006;296(8):964–73. 10.1001/jama.296.8.964 . Anzivino E, Fioriti D, Mischitelli M, Bellizzi A, Barucca V, Chiarini F, et al. Herpes simplex virus infection in pregnancy and in neonate: status of art of epidemiology, diagnosis, therapy and prevention. Virol J. 2009;6:40. 10.1186/1743-422X-6-40 . Harrison B, Clarke E. Disseminated herpes simplex virus in pregnancy: a systematic review of cases. J Obstet Gynaecol Res. 2025;51(11):e70115. 10.1111/jog.70115 . Young EJ, Chafizadeh E, Oliveira VL, Genta RM. Disseminated herpesvirus infection during pregnancy. Clin Infect Dis. 1996;22(1):51–8. 10.1093/clinids/22.1.51 . Brown ZA, Selke S, Zeh J, Kopelman J, Maslow A, Ashley RL, et al. The acquisition of herpes simplex virus during pregnancy. N Engl J Med. 1997;337(8):509–15. 10.1056/NEJM199708213370801 . Sauerbrei A. Herpes genitalis: diagnosis, treatment and prevention. Geburtshilfe Frauenheilkd. 2016;76(12):1310–7. 10.1055/s-0042-116494 . Calix RX, Loeliger KB, Burn MS, Campbell KH. Acute herpes simplex virus hepatitis in pregnancy. Obstet Gynecol. 2020;135(2):396–400. 10.1097/AOG.0000000000003640 . Courts and Tribunals Judiciary. Kimberley Sampson and Samantha Mulcahy: Prevention of Future Deaths Report [Internet]. London: Courts and Tribunals Judiciary; 2023 [cited 2026 Jan 17]. Available from: https://www.judiciary.uk/prevention-of-future-death-reports/kimberley-sampson-and-samantha-mulcahy/ Flewett TH, Parker RG, Philip WM. Acute hepatitis due to herpes simplex virus in an adult. J Clin Pathol. 1969;22(1):60–6. 10.1136/jcp.22.1.60 . Bougioukas L, Psoinos C, Jones RB, Morris DC, Hale AJ. Disseminated herpes simplex virus-2 as a complication of pregnancy. IDCases. 2021;24:e01107. 10.1016/j.idcr.2021.e01107 . McCormack AL, Rabie N, Whittemore B, Murphy T, Sitler C, Magann E. HSV hepatitis in pregnancy: a review of the literature. Obstet Gynecol Surv. 2019;74(2):93–8. 10.1097/OGX.0000000000000642 . Norvell JP, Blei AT, Jovanovic BD, Levitsky J. Herpes simplex virus hepatitis: an analysis of the published literature and institutional cases. Liver Transpl. 2007;13(10):1428–34. 10.1002/lt.21250 . Wagstaff AJ, Faulds D, Goa KL. Aciclovir. A reappraisal of its antiviral activity, pharmacokinetic properties and therapeutic efficacy. Drugs. 1994;47(1):153–205. 10.2165/00003495-199447010-00009 . Pasternak B, Hviid A. Use of acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy and the risk of birth defects. JAMA. 2010;304(8):859–66. 10.1001/jama.2010.1206 . Solomon T, Michael BD, Smith PE, Sanderson F, Davies NWS, Hart IJ, et al. Management of suspected viral encephalitis in adults: Association of British Neurologists and British Infection Association national guidelines. J Infect. 2012;64(4):347–73. 10.1016/j.jinf.2011.11.014 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9130561","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":620649240,"identity":"8209b1c7-d903-4452-b1dd-58b3733428c2","order_by":0,"name":"Raeghan O’Leary","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYFAC9uM/JCpq6vsZEhgPEKmFJ0HC4swxxpkNCQzEamEwkKhsYWbccIBYLeb9CxIMbjawMRsfT35wgKHGjrAWmRsPDyTO3CHDZnbmmcEBhmPJhLVISBxIOCx5ho3H7EaCwQHGBmaitBg2/21jljCekf4BqKWeCC38DcYMkm3MBgYSOSBbDhNjC08ag8SZYwkSZ94UHEg4dpwYW44fYwBGZQJ/e/rGBx9qqglrYZBIQOIk4FCECvgPEKVsFIyCUTAKRjIAAP7nP1XHZvYrAAAAAElFTkSuQmCC","orcid":"","institution":"Dalhousie Medicine New Brunswick","correspondingAuthor":true,"prefix":"","firstName":"Raeghan","middleName":"","lastName":"O’Leary","suffix":""},{"id":620649241,"identity":"18b543e9-e808-49f3-9e8f-972bedac7877","order_by":1,"name":"Jaskaranvir Singh-Ranger","email":"","orcid":"","institution":"Queen's University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Jaskaranvir","middleName":"","lastName":"Singh-Ranger","suffix":""},{"id":620649245,"identity":"b95760c3-d702-4e41-9fe3-9ebb75e2019d","order_by":2,"name":"Gurpreet Singh-Ranger","email":"","orcid":"","institution":"Horizon Health Network","correspondingAuthor":false,"prefix":"","firstName":"Gurpreet","middleName":"","lastName":"Singh-Ranger","suffix":""}],"badges":[],"createdAt":"2026-03-15 18:23:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9130561/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9130561/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106961478,"identity":"654a4259-81c2-4891-9807-296b2c6c5e20","added_by":"auto","created_at":"2026-04-15 09:25:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":484091,"visible":true,"origin":"","legend":"\u003cp\u003eChest radiograph obtained on admission showing mild bilateral atelectasis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9130561/v1/7c3e1d850b6eca05ffce203d.png"},{"id":106947102,"identity":"17ecc85c-be31-4998-be13-24ae1b8f7433","added_by":"auto","created_at":"2026-04-15 06:48:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":429819,"visible":true,"origin":"","legend":"\u003cp\u003eChest computed tomography on admission demonstrating bilateral atelectasis and a small right pleural effusion.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9130561/v1/7ae16bd682aa1a757422ae9f.png"},{"id":106963362,"identity":"60f73a12-8ddb-4dd8-8928-d238a43907f1","added_by":"auto","created_at":"2026-04-15 09:43:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1349083,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9130561/v1/a9e5fdd0-b368-429e-b125-be85015b6eae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disseminated Herpes Simplex Virus Presenting as Postpartum Sepsis: A Rural Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInfection with herpes simplex virus (HSV) is relatively common in North America and usually is a localized, self-limiting condition. Approximately 12% of individuals aged 14\u0026ndash;49 years in the United States are seropositive for HSV-2, which traditionally has been the main cause of genital herpes \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. However, in the last decade, there has been an increasing number of genital infections due to the HSV-1 virus, which is the most common cause of oral herpes \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. HSV incidence is highest in women of reproductive age; therefore, the risk of maternal transmission to fetuses and neonates is a major health concern \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDisseminated HSV infection is a rare but life-threatening complication, particularly in pregnancy and the postpartum period \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. It is associated with high maternal and neonatal mortality and can present with nonspecific features \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Approximately 20\u0026ndash;25% of women in pregnancy are seropositive for HSV-2, and approximately 2\u0026ndash;3% of seronegative women will acquire a primary HSV infection during pregnancy \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA systematic review of 114 published cases over a 60-year period found that presenting symptoms of disseminated HSV included altered liver function, gastrointestinal symptoms, respiratory challenges, fever, and neuropsychiatric symptoms, and most did not have mucocutaneous lesions at presentation \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Therefore, disseminated HSV infection may mimic bacterial sepsis, HELLP syndrome, or acute fatty liver of pregnancy and often has a late diagnosis, leading to a delay in appropriate treatment \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEarly recognition of disseminated HSV is critical, and maternal survival has been shown to be significantly higher among those who are treated with acyclovir than those who are not \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In 2018, coroner\u0026rsquo;s reports from the United Kingdom described two fatal cases of disseminated HSV infection shortly after cesarean section at the same hospital, within weeks of each other \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Both cases presented with suspected bacterial sepsis and did not respond to antibiotics \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Unfortunately, antiviral treatment was initiated too late in the disease course, and both patients died \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite the high morbidity and mortality associated with disseminated HSV in pregnancy and the postpartum period, it is not consistently addressed in sepsis guidelines \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. HSV is acknowledged in obstetric-specific guidelines, but these resources are often not accessed until after HSV is clinically considered and suspected \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Therefore, guidelines in emergency and acute care settings may not prompt clinicians to consider disseminated HSV, especially in the absence of mucocutaneous lesions \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. This gap has been recently highlighted in the literature, emphasizing that disseminated HSV frequently presents with non-specific features and may be misdiagnosed as bacterial sepsis, resulting in delayed antiviral therapy and preventable mortality.\u003c/p\u003e \u003cp\u003eWe report a case of disseminated HSV that presented 4 days after an uncomplicated caesarean section, manifesting as severe sepsis unresponsive to broad-spectrum antibiotics. This case highlights the diagnostic challenges of disseminated HSV in the postpartum period and the importance of early empiric antiviral therapy, especially in rural settings where confirmatory testing is not immediately available.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 23-year-old 39-week pregnant woman (gravida 4, para 0, abortus 3) presented in labour to our rural facility in May 2023. An emergency caesarean section was called by the family physician managing the labour due to non-reassuring fetal heart rate tracing. The procedure was uncomplicated, with minimal blood loss, and a healthy female infant weighing 3660g was delivered. Post-operatively, the patient's condition was unremarkable, and they were discharged home 72 hours after delivery.\u003c/p\u003e \u003cp\u003eTwenty-four hours following discharge (post-operative day 4), the patient re-presented with fever, exertional dyspnea, pleuritic chest pain, and generalized myalgia. Her temperature was 38.3\u0026deg;C, blood pressure 98/56 mmHg, heart rate 125 beats/min, and oxygen saturation 96% on 2 L/min supplemental oxygen. She was anxious, but alert and oriented. Non-pitting peripheral edema was present, and respiratory examination demonstrated decreased breath sounds bilaterally.\u003c/p\u003e \u003cp\u003eGiven concern for pulmonary embolism, urgent computed tomography (CT) pulmonary angiography was performed, which demonstrated a small right pleural effusion and basal atelectasis, the latter also seen on chest radiograph (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no evidence of pulmonary emboli. CT abdomen and pelvis were unremarkable. The small pleural effusion was not considered clinically significant. Examination of the caesarean section wound revealed mild operative tenderness without erythema, discharge, or cutaneous lesions. Laboratory investigations demonstrated leukocytosis, markedly elevated C-reactive protein, and elevated alkaline phosphatase, with normal amylase, creatine kinase, and troponin levels (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the absence of an alternative diagnosis, sepsis with evolving shock physiology was suspected based on her inflammatory markers, hypotension, tachycardia, and respiratory symptoms.\u003c/p\u003e \u003cp\u003eThe patient was admitted and started on intravenous piperacillin\u0026ndash;tazobactam (4.5g every 6 hours) and intravenous fluid resuscitation. Blood, urine, and sputum cultures were negative. Despite broad-spectrum antibiotic therapy, she experienced worsening dyspnea, chest pain, peripheral edema, persistent pyrexia, and rising inflammatory markers (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) over the following 48 hours. An internal medicine consultation was obtained, and diuretic therapy was initiated for suspected cardiac dysfunction. There was no clinical improvement, and on post-admission day 2, further history revealed a prior diagnosis of genital herpes simplex virus infection during pregnancy. At that time, no mucocutaneous lesions were noted on examination.\u003c/p\u003e \u003cp\u003eGiven the lack of response to antibiotics and the clinical history, empirical intravenous acyclovir therapy was started. The patient demonstrated rapid clinical improvement within 48 hours, with resolution of her fever and respiratory symptoms, marked declines in inflammatory markers, and improved liver enzymes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Blood and urine cultures remained negative, as did screening for methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, SARS-CoV-2, and influenza. On post-admission day 5, 3 days after initiation of acyclovir, several vesicular lesions consistent with herpes simplex virus infection developed adjacent to the caesarean section wound. HSV polymerase chain reaction (PCR) testing was not available to confirm the diagnosis.\u003c/p\u003e \u003cp\u003eThe patient completed a 10-day inpatient course and was discharged home on oral acyclovir. At follow-up, 1 week after discharge (Day 21) she remained clinically well. The neonate remained asymptomatic throughout and did not require antiviral therapy. A summary of the clinical course is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSerial laboratory results during the patient\u0026rsquo;s clinical course.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(Admission to facility)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 week\u003c/p\u003e \u003cp\u003ePost discharge\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntimicrobial\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eTherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIV antibiotics\u003c/p\u003e \u003cp\u003epiperacillin tazobactam 4.5g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eIV acyclovir\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOral acyclovir\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhite count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelets\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e546\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCreatinine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ebilirubin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e243.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e369.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e432.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e232.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e184.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e107.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTimeline of clinical course.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Event\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaesarean section performed for non-reassuring fetal heart tracing. Healthy infant delivered.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient and baby discharged home in stable condition.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRe-presented with fever, dyspnea, pleuritic chest pain, and myalgia. CT pulmonary angiography showed basal atelectasis and small pleural effusion. Patient admitted, and broad-spectrum antibiotics were initiated.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 6 (Admission Day 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent fever and worsening inflammatory markers despite antibiotics. History of genital HSV disclosed and IV acyclovir initiated.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 8 (Admission Day 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarked clinical improvement. Inflammatory markers began declining.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 9 (Admission Day 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMucocutaneous vesicular lesions developed near the caesarean section incision site.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 14 (Admission Day 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompleted inpatient treatment and discharged home on oral acyclovir.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 21 (Follow-Up)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient clinically well. Neonate remained asymptomatic.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDisseminated HSV in pregnancy and postpartum remains a rare, potentially devastating condition. It is more commonly described during pregnancy and often presents with encephalitis, hepatitis, disseminated skin lesions, and disease that also affects the newborn \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. In a systematic review by Harrison and Clarke, postpartum infections accounted for fewer than 10% of reported cases, with a median presentation at 6 days post-delivery \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur patient re-presented 4 days after an uncomplicated caesarean section with fever, dyspnea, pleuritic chest pain, and laboratory evidence of systemic inflammation with hepatic involvement. As in previously reported cases, examination of her skin did not reveal mucocutaneous lesions, and she was initially managed as presumed bacterial sepsis. Harrison and Clarke emphasize the diagnostic value of speculum examination, noting that 44.4% of genital herpes lesions were confined to the vagina or cervix and would not have been identified without internal examination \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Speculum examination was not performed for this patient as she was admitted under general surgery, the responsible service for caesarean sections at our rural facility, and the value that this examination may provide was not appreciated at the time. Departmental practice has been changed subsequently to include speculum examination in all patients presenting with sepsis post-caesarean section. Additional training for staff has also been provided.\u003c/p\u003e \u003cp\u003eMildly abnormal liver enzyme tests were a notable laboratory finding in our patient (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Abnormal liver function during disseminated HSV is common, \u003csup\u003e4, 10\u003c/sup\u003e and hepatic involvement may be present in over 70% of cases \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. While elevated alkaline phosphatase may be physiological in pregnancy, associated transaminitis should prompt consideration of viral hepatitis, including HSV \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Similar findings have been reported in analyses of HSV hepatitis, where abnormal liver enzymes serve as an early diagnostic clue \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePostpartum fever with non-specific symptoms and sepsis unresponsive to antibiotics is a key feature of disseminated HSV infection \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Early empiric treatment with acyclovir is critical. Harrison and Clarke describe a marked difference in maternal survival observed with acyclovir treatment (0.88 vs 0.42), supporting a low threshold for initiating antiviral therapy in a postpartum patient presenting with sepsis refractory to antibiotics \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In our case, intravenous acyclovir was started following recognition of antibiotic non-response and history of genital HSV infection, leading to a rapid improvement and clinical diagnosis of disseminated HSV. This was further supported by the subsequent development of vesicular lesions near the caesarean incision site.\u003c/p\u003e \u003cp\u003eRural practice settings contribute to the delayed diagnosis of disseminated HSV. For example, access to rapid HSV diagnostic testing is often limited. Confirmatory PCR testing requires transport to a reference laboratory, and results may take up to two weeks to return to our facility. In suspected disseminated HSV, this delay limits the clinical utility of confirmatory testing for acute management. Another challenge at rural sites may be a lack of specialty coverage, which can lead physicians to practice more generally. A speculum examination may have facilitated earlier recognition, but there was no access to on-site obstetrical consultation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePostpartum disseminated HSV diagnosis is complex, as symptoms are non-specific, may mirror other pregnancy or post-operative complications, and patients frequently report no history of HSV \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Coroner\u0026rsquo;s reports in the United Kingdom illustrate the fatal nature of disseminated HSV following caesarean section when antiviral therapy is not initiated promptly \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Clinicians should maintain a high index of suspicion for disseminated HSV in postpartum patients who fail to respond to standard sepsis management, particularly as HSV is not consistently addressed in general sepsis guidelines. Given acyclovir's safety profile, availability, and potential life-saving benefit \u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, empiric antiviral therapy should be strongly considered \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Early recognition may significantly influence patient outcomes, as delays in treatment may result in significant morbidity and mortality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eEthics/Consent for publication\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEthical approval\u0026nbsp;was not required for this case report in accordance with institutional policy. Written informed consent was obtained from the patient for publication of this case report and associated images.\u003c/p\u003e\n\u003ch2\u003eCARE Statement\u003c/h2\u003e\n\u003cp\u003eThis case report was prepared in accordance with CARE reporting guidelines, and a CARE checklist has been completed.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo funding was received for this work.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eRO contributed to the literature review, drafting of the manuscript, and preparation of figures and tables. JSR contributed to literature review. GSR contributed to interpretation of the clinical findings. All authors reviewed the manuscript and completed edits.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcQuillan G, Kruszon-Moran D, Flagg EW, Paulose-Ram R. 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Use of acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy and the risk of birth defects. JAMA. 2010;304(8):859\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2010.1206\u003c/span\u003e\u003cspan address=\"10.1001/jama.2010.1206\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolomon T, Michael BD, Smith PE, Sanderson F, Davies NWS, Hart IJ, et al. Management of suspected viral encephalitis in adults: Association of British Neurologists and British Infection Association national guidelines. J Infect. 2012;64(4):347\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jinf.2011.11.014\u003c/span\u003e\u003cspan address=\"10.1016/j.jinf.2011.11.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"virology-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"virj","sideBox":"Learn more about [Virology Journal](http://virologyj.biomedcentral.com/)","snPcode":"12985","submissionUrl":"https://submission.nature.com/new-submission/12985/3","title":"Virology Journal","twitterHandle":"@VirologyJ","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Herpes simplex virus, caesarean section, acyclovir, postpartum sepsis, case report","lastPublishedDoi":"10.21203/rs.3.rs-9130561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9130561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eInfection with disseminated herpes simplex virus (HSV) in pregnancy and the postpartum period can be a potentially devastating condition. Postpartum presentations may mimic bacterial sepsis and frequently present without mucocutaneous lesions, which can delay diagnosis and treatment. The purpose of this report is to highlight the diagnostic challenges of disseminated HSV presenting as postpartum sepsis and to emphasize the importance of early empiric antiviral therapy, especially at rural sites where rapid polymerase chain reaction (PCR) testing is not available.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe present the case of a 23 year old woman at 39 weeks\u0026rsquo; gestation (gravida 4, para 0, abortus 3) who delivered a female infant via caesarean section. They were discharged from the hospital after 72 hours with no health concerns. Four days post-operatively, the patient re-presented and was admitted due to fever, exertional dyspnea, pleuritic chest pain, and generalized myalgia. Laboratory results and clinical observations were suggestive of septic shock, and intravenous (IV) antibiotics were started.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDespite broad-spectrum antibiotic therapy, the patient remained unwell. On post-admission day 2, she disclosed a recent history of genital herpes infection several weeks prior to her caesarean section. IV acyclovir was started immediately, as our rural facility does not have access to on-site HSV PCR testing. Clinical improvement followed and vesicular lesions later developed near the caesarean site, supporting the diagnosis of disseminated HSV. The neonate remained asymptomatic through the clinical course.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis case illustrates the diagnostic uncertainty that may arise when disseminated HSV presents as postpartum sepsis. Clinicians should maintain a high index of suspicion for HSV infection in postpartum patients who fail to respond to antibiotic therapy, as early empiric antiviral treatment may significantly influence patient outcomes.\u003c/p\u003e","manuscriptTitle":"Disseminated Herpes Simplex Virus Presenting as Postpartum Sepsis: A Rural Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-15 06:48:18","doi":"10.21203/rs.3.rs-9130561/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-10T20:54:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324702869195693883636034376164967689060","date":"2026-05-04T17:08:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54132731595288646735013020643057729871","date":"2026-05-04T17:06:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T10:24:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44287229964260472394697008517844924363","date":"2026-04-24T01:10:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-07T16:55:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-16T22:16:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-16T22:15:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Virology Journal","date":"2026-03-15T18:07:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"virology-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"virj","sideBox":"Learn more about [Virology Journal](http://virologyj.biomedcentral.com/)","snPcode":"12985","submissionUrl":"https://submission.nature.com/new-submission/12985/3","title":"Virology Journal","twitterHandle":"@VirologyJ","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59d99a0e-d2d9-4789-b8bd-53ca1b3b25e9","owner":[],"postedDate":"April 15th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-10T20:54:40+00:00","index":27,"fulltext":""},{"type":"reviewerAgreed","content":"324702869195693883636034376164967689060","date":"2026-05-04T17:08:46+00:00","index":26,"fulltext":""},{"type":"reviewerAgreed","content":"54132731595288646735013020643057729871","date":"2026-05-04T17:06:08+00:00","index":25,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T06:48:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-15 06:48:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9130561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9130561","identity":"rs-9130561","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}