A Man with Acute Liver Injury

Posted by • November 24th, 2016

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HEV infection is uncommon in the United States, although 20% of the population has antibodies to HEV. The diagnosis should be considered in patients who present with acute hepatitis after returning from a trip to an area in which HEV is endemic. In a new Case Record article, a 50-year-old man from India with a remote history of alcohol use was admitted to the hospital because of abnormal liver function test results, anemia, and acute kidney injury. A diagnosis was made.

Clinical Pearl

What are some of the features of HEV infection?

HEV is endemic throughout Central and Southeast Asia, India, the Middle East, North Africa, and Mexico. In these areas, HEV is a major cause of acute hepatitis and acute liver failure, with high attack rates among adults between 15 and 40 years of age. HEV is transmitted enterically and is responsible for waterborne outbreaks of hepatitis; person-to-person transmission is uncommon. The mean incubation period is 40 days. A high mortality rate (15 to 25%) occurs among pregnant women. The risk of hepatic decompensation is increased in patients with underlying chronic liver disease.

Clinical Pearl

What is the usual course of hepatitis E virus infection?

Illness is generally self-limited, but cases of chronic hepatitis attributed to HEV that have progressed rapidly to cirrhosis have been reported in transplant recipients and, rarely, in persons with human immunodeficiency virus infection or preexisting liver disease or in those undergoing chemotherapy for cancer.

Morning Report Questions

Q: Are there reliable serologic tests for diagnosing acute hepatitis E available in the United States? 

A: The diagnosis of acute hepatitis E is made most readily by testing for anti-HEV IgM antibodies in serum, although available tests may not be reliable and are not licensed for use in the United States. The diagnosis can also be made by detecting HEV in serum or stool with the use of a polymerase-chain-reaction (PCR) assay. A liver biopsy is generally unnecessary. However, serologic testing for HEV should be interpreted with caution, because the test has several limitations, including variability in the sensitivity and specificity of tests available in the United States.

Q: Is there an established role for antiviral therapy in cases of acute hepatitis E infection? 

A: Antiviral treatments for acute HEV infection have not been well studied; most of the literature on treatment involves reports of immunocompromised patients with chronic HEV infection. When decreasing the immunosuppression is not feasible or does not lead to viral clearance, antiviral therapy with pegylated interferon alone or in combination with ribavirin has been shown to be effective. Whether antiviral treatment with ribavirin improves outcomes in patients with severe acute HEV infection is unknown, but several case reports suggest a benefit. However, ribavirin is also associated with a substantial risk of hemolytic anemia. There is evidence that acute HEV infection can resolve without antiviral therapy.

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