Case history
Case history
A 49-year-old woman presents with several days of fatigue, loss of appetite, and abdominal pain. She recently returned from a month-long culinary tour of Europe where she visited multiple wineries and farms and tried various local dishes. Exam shows normal vital signs, scleral icterus, and a soft abdomen. Laboratory studies show an alanine aminotransferase of 809 IU/L, a total bilirubin of 7.8 mg/dL, and an international normalized ratio (INR) of 1.1. Serum IgM anti-hepatitis E antibodies are positive.
Other presentations
Patients with HEV infection may present with an acute hepatitis that is usually self-limited. Many patients with acute infection can be asymptomatic, although acute liver failure can less commonly occur. Extrahepatic manifestations are numerous but uncommon, and may include neurologic conditions (e.g., Guillain-Barré syndrome, neuralgic amyotrophy, meningitis), acute renal disease, hematologic dysfunction with hemolysis and thrombocytopenia, acute pancreatitis, thyroiditis, and myocarditis.[2][9]
HEV infection in some groups is associated with significant mortality and morbidity. Acute HEV infection in pregnancy in endemic areas can lead to acute liver failure in upwards of 20% of women.[10] The mechanism behind this is unclear but may be exacerbated by malnutrition. Acute HEV infection in patients with underlying liver disease or cirrhosis can also be particularly severe.[2][11] A prolonged cholestatic hepatitis where jaundice can last for more than 3 months has been noted in patients with acute HEV, but complete recovery is the rule, usually within a few months and with clearance of HEV RNA.[12]
Chronic HEV infection is almost always seen in immunosuppressed patients, such as recipients of solid organ transplants and those with HIV infection, and appears to be related to their impaired T-cell response.[2][13]
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