Hepatitis E virus infection increases the risk of diabetes and severity of liver disease in patients with chronic hepatitis C virus infection

OBJECTIVES: Co-infection with hepatitis A or B viruses may aggravate liver injury in patients infected with hepatitis C virus (HCV). However, few studies have assessed co-infection with hepatitis E virus (HEV) and HCV. Therefore, this study aimed to assess the prevalence and impact of HEV infection among Brazilian patients with chronic HCV infection. METHODS: This observational study included adult patients with chronic HCV infection who were naive to antiviral therapy from January 2013 to March 2016. A total of 181 patients were enrolled, and HEV serology and PCR were performed for all patients. RESULTS: Seropositivity for anti-HEV IgG was detected in 22 (12.0%) patients and anti-HEV immunoglobulin M in 3 (1.6%). HEV RNA showed inconclusive results in nine (4.9%) patients and was undetectable in the remaining patients. HEV serology positive patients had more severe liver disease, characterized by liver fibrosis ≥3 versus ≤2 (p<0.001), Aspartate Aminotransferase-to-Platelet Ratio Index of ≥1.45 (p=0.003), and Fibrosis-4 score of ≥3.25 (p=0.001). Additionally, the odds of HEV-positive patients developing diabetes mellitus were 3.65 (95% CI 1.40-9.52) times the corresponding odds of HEV-negative patients. A case-control-based histological analysis (n=11 HEV-HCV-positive patients and n=22 HCV-positive patients) showed no significant differences between the groups. CONCLUSIONS: This prevalence is higher than that reported in previous studies of the general population in Brazil. Thus, HEV infection may influence the severity of liver disease and may represent an additional risk of developing diabetes mellitus in patients with HCV infection.

Hepatitis A and hepatitis E virus co-infection with right pleural effusion, ascites and acute acalculous cholecystitis. A case report / Coinfección por el virus de la hepatitis A y la hepatitis E con derrame pleural derecho, ascitis y colecistitis acalculosa aguda. Reporte de caso

ABSTRACT Hepatitis A and hepatitis E are the leading causes of acute viral hepatitis in developing countries due to our poor sanitary conditions, both spread by fecal-oral route or through contaminated water and food. Being both self-limiting diseases, they are usually benign but may present with atypical clinical findings. A 32 year-old female with right pleural effusion, ascites and acalculous cholecystitis during the course of HAV and HEV co-infection is reported. Clinical improvement was observed with conservative management. As far as we know, this is the first case described of a patient with these three complications in the background of a hepatitis A virus and hepatitis E virus co-infection.

RESUMEN Hepatits A y hepatitis E son las principales causas de hepatitis viral en países en desarrollo debido a las limitadas condiciones sanitarias. Son condiciones usualmente benignas y autolimitadas, pero pueden presentarse de forma atípica. Se reporta una paciente de 32 años con efusión pleural derecha, colecistitis acalculosa y ascitis en el curso de una co-infección por el virus de Hepatitis A y hepatitis E. Hasta donde tenemos conocimiento, este es el primer caso de una paciente con estas tres complicaciones como resultado de una infección por el virus de hepatitis A y hepatitis E.

Virus de la hepatitis E en una gestante joven / Hepatitis E virus in a young pregnant woman

Se presenta el caso clínico de una gestante de 20 años de edad, nulípara, con antecedente de asma intermitente, asintomática, quien ingresó con un síndrome ictérico en el Hospital Ginecoobstétrico Mariana Grajales Coello de Santiago de Cuba. Luego de realizarle los estudios pertinentes se concluyó que presentaba una hepatitis E complicada, la cual requirió cuidados intensivos; con el diagnóstico oportuno y el tratamiento eficaz se pudo garantizar su supervivencia

The case report of a 20 years nulliparous pregnant woman with history of intermittent, asymptomatic asthma is presented, who was admitted with an icteric syndrome in Mariana Grajales Coello Gynecoobstetric Hospital of Santiago de Cuba. After carrying out him the pertinent studies it was concluded that she presented a complicated hepatitis E, which required intensive cares; with the opportune diagnosis and the effective treatment her survival could be guaranteed

Hepatitis E virus seroprevalence among schistosomiasis patients in Northeastern Brazil

Abstract Background Hepatitis E virus (HEV) can cause chronic infection with rapid progression to liver cirrhosis in immunocompromised patients. HEV seroprevalence in patients with Schistosoma mansoni in Brazil is unknown. We evaluated the prevalence of past or present HEV infection in schistosomiasis patients in Recife, Pernambuco, Brazil. A total of 80 patients with Schistosoma mansoni were consecutively enrolled in a cross-sectional study. Serum samples were tested for the presence of anti-HEV IgG antibodies by enzyme immunoassay (Wantai anti-HEV IgG, Beijing, China) and for the presence of HEV RNA using real time reverse transcriptase-polymerase chain reaction with primers targeting the HEV ORF2 and ORF3. Clinical and laboratory tests as well as abdominal ultrasound were performed at the same day of blood collection. Results Anti-HEV IgG was positive in 18.8% (15/80) of patients with SM. None of the samples tested positive for anti-HEV IgM or HEV-RNA. Patients with anti-HEV IgG positive presented higher levels of alanine aminotranferase (p = 0.048) and gama-glutamil transferase (p = 0.022) when compared to patients without anti-HEV IgG antibodies. Conclusion This study demonstrates that the seroprevalence of HEV is high in patients with Schistosoma mansoni in Northeastern of Brazil. Past HEV infection is associated with higher frequency of liver enzymes abnormalities. HEV infection and its role on the severity of liver disease should be further investigated among patients with Schistosoma mansoni.

Anemia aplásica asociada a hepatitis E: Informe de un caso

La aplasia medular asociada a hepatitis (HAAA) es una reconocida entidad clínica donde la falla medular es precedida de una hepatitis; se observa hasta en el 5% de las aplasias en Europa occidental y América del Norte y hasta en el 10% de ellas en el Este asiático. Se ha sospechado de los virus hepatotropos y otros virus como responsables de HAAA, pero esta asociación raramente se ha confirmado. La hepatitis por virus E es la causa más frecuente de hepatitis viral en el mundo. Su genotipo 3, de mayor circulación en la Argentina y otros países de Latinoamérica, puede presentar complicaciones extrahepáticas (renales, neurológicas, pancreáticas y hematológicas). Hasta aquí, en nuestro conocimiento solo se ha publicado un caso de HAAA por virus de la hepatitis E en Pakistán; el que ahora presentamos sería el primero comunicado en la Argentina. La paciente fue tratada con timoglobulina, ciclosporina, corticosteroides, filgastrim y soporte transfusional. Desarrolló fungemia por Candida tropicalis que respondió a equinocandinas, y luego infiltrados pulmonares e imagen nodular cerebral con galactomananos en suero (índice DO > 1.0 ng/ml) que resolvieron con voriconazol. Fue dada de alta independiente de transfusiones, tres meses después de su admisión, con hepatograma normal. Teniendo en cuenta este caso, sería conveniente investigar la hepatitis E como causa de HAAA en la Argentina.

Hepatitis-associated aplastic anemia (HAAA) is a well-recognized clinical syndrome in which marrow failure follows the development of hepatitis; it can be observed in up to 5% in the aplastic anemia in West Europe and North American countries and 10% in the East Asia. Although hepatotropic and other viruses were suspected of causing HAAA, this hypothesis was rarely confirmed. Currently, the infection with hepatitis E virus represents the first cause of acute hepatitis in the world. Its genotype 3, the most frequent in Argentina and other Latin American countries, was associated with extrahepatic complications (renal, pancreatic, neurologic and hematologic). To our knowledge, only one case of hepatitis E virus-associated aplastic anemia has been previously reported, in Pakistan; the case presented here would be the first in Argentina. The patient was treated with thymoglobulin, cyclosporine, corticosteroids, filgastrim and transfusional support. She developed fungemia due to Candida tropicalis that remitted with equinocandins and therefore fever, pulmonary infiltrates and a solitary nodular cerebral image with serum galactomannan (DO index > 1.0 ng/ml) that resolved with voriconazol. She was discharged three months after her admission without transfusion requirements and normal hepatic values.With this in mind, it would be advisable to investigate hepatitis E (HEV) as a cause of HAAA in Argentina.

Coinfection of hepatitis A virus genotype IA and IIIA complicated with autoimmune hemolytic anemia, prolonged cholestasis, and false-positive immunoglobulin M anti-hepatitis E virus: a case report / 대한간학회지

A 37-year-old male presented with fever and jaundice was diagnosed as hepatitis A complicated with progressive cholestasis and severe autoimmune hemolytic anemia. He was treated with high-dose prednisolone (1.5 mg/kg), and eventually recovered. His initial serum contained genotype IA hepatitis A virus (HAV), which was subsequently replaced by genotype IIIA HAV. Moreover, at the time of development of hemolytic anemia, he became positive for immunoglobulin M (IgM) anti-hepatitis E virus (HEV). We detected HAV antigens in the liver biopsy specimen, while we detected neither HEV antigen in the liver nor HEV RNA in his serum. This is the first report of hepatitis A coinfected with two different genotypes manifesting with autoimmune hemolytic anemia, prolonged cholestasis, and false-positive IgM anti-HEV.

Hepatitis E en niños / Hepatitis E in children

La hepatitis E, conocida previamente como hepatitis no A, no B, de transmisión enteral, es una infección causada por el virus de la hepatitis E (VHE), cuyas características clínicas y epidemiológicas son las de una hepatitis aguda. Pertenece a la familia Hepaviridae. El VHE setransmite principalmente por la vía fecal-oral, la mayoría de las epidemias se pueden asociar conbrotes que tienen su origen en el agua, alta densidad de población y deficientes condiciones sanitarias. El cuadro clínico es el de una hepatitis aguda típica, sin embargo, tiene un amplio espectro de presentación clínica. Es común encontrar marcadores serológicos para VHE positivos en niños con hepatitis viral aguda por otros virus hepatótropos, especialmente el virus B y C. El diagnóstico de infección por VHE se puede hacer por detección serológica y/o molecular. La teórica viabilidad de una vacuna frente alVHEestá basada en diversas evidencias.

Hepatitis E, formerly known as hepatitis non A, non B, enteral transmission, is an infection causedby the hepatitis E virus (HEV), clinical and epidemiological characteristics are those of acute hepatitis. Hepaviridae belongs to the family. HEV is transmitted primarily through fecal-oral route,most outbreaks have been associated with outbreaks that have their origin in water, high population density and poor sanitation. The clinical picture is that of a typical acute hepatitis, however, has a broad spectrum of clinical presentation. Commonly found positive for HEV serological markers in children with acute viral hepatitis other hepatotropic viruses, especially viruses B and C. The diagnosis of HEV infectionan be done by serological detection and/or molecular. The theoretical feasibility of a vaccineagainstHEVis based on different evidence.

Seroprevalence of subclinical HEV infection in pregnant women from north India: A hospital based study.

Background & objectives: Hepatitis E virus (HEV) is a major public health problem in the developing countries. HEV infection in pregnant women is more common and fatal in the third trimester. The mortality rate due to HEV-induced hepatitis is as high as 15-20 per cent. The present study was designed to determine the seroprevalence of subclinical HEV infection in pregnant primigravidae women. Methods: A total of 300 asymptomatic healthy primigravidae (gestational age 16-24 wk) with no history of jaundice were included in the study. Prevalence of anti-HEV antibodies was determined by an enzyme linked immunosorbent assay (ELISA) kit. Results: The overall prevalence of seropositive HEV IgG was 33.67 per cent among the pregnant women. The seropositivity of HEV IgG was significantly high in urban population (P<0.05), and related with the period of settlement (P<0.05) and source of water (P=0.05). Low socio-economic status of the pregnant women appeared to be the only risk factor (OR=1.96, CI=1.17-3.28) associated with HEV IgG antibody. Interpretation & conclusions: In the present study, exposure to HEV during pregnancy was higher in urban (slum areas) than rural population. Socio-economic status was a risk factor for anti-HEV IgG in pregnant women. Early preventive measures if taken, may decrease the maternal and perinatal mortality and morbidity of HEV infection.

Acute liver failure caused by hepatitis E virus and paracetamol.

Acute liver failure is characterized by severe and sudden liver cell dysfunction leading to hepatic encephalopathy and hepatic coagulopathy in a person without history of liver disease in the past. This catastrophic illness can rapidly progress to coma and death from cerebral edema and multi organ dysfunction. It carries a high mortality rate if liver transplantation is not carried out. In West, paracetamol is the main cause of hepatotoxicity whereas in the East viral hepatitis tops the list. This report describes a case of acute liver failure in which probably both the agents were involved. The patient recovered with antidote therapy and maximum supportive care.

Hepatitis E virus infection in chronic liver disease causes rapid decompensation.

Hepatitis E previously known as enterically transmitted non-A, non-B hepatitis, is a self limiting infectious viral disease of developing countries. Various issues regarding the pathogenesis of liver injury and its natural history remain unanswered after two decades of its discovery. A small proportion of patients develop fulminant hepatic failure. Mortality is very high if it is associated with pregnancy, especially during third trimester. After establishment of hepatitis A virus as a cause of decompensation of chronic liver disease, now there are reports that hepatitis E viruses also does the same. Acute hepatitis E in these patients has a protracted course with high morbidity and mortality. Many patients develop hepatorenal syndrome, hepatic encephalopathy and even liver failure after co-infection with hepatitis E virus. Now time has come to institute hepatitis E virus superinfection as one of the cause of acute on chronic liver failure. Hepatitis E is a problem of developing countries and Nepal is in the endemic zone. Sudden decompensation in chronic liver disease patient, who were otherwise stable and under regular follow up, should be carefully dealt with. Patient statistics at our unit shows that 7 cases of chronic liver diseases with superinfection with hepatitis E virus were dealt from April 2004 to August 2005. Two patients (29%) died and 5 recovered. In patients with recovery, there was deterioration of Child-Pugh grading and the duration of hospital stay was longer. Thus, hepatitis E in diagnosed chronic liver disease case should be taken apprehensively. Similarly patients of chronic liver disease traveling to endemic zone should take precaution. If vaccine against hepatitis E virus is developed, chronic liver disease patient would be the eligible candidate for vaccination beside pregnant ladies.

Acute hepatitis E in pregnancy--study of 16 cases.

This retrospective study was done at Tribhuvan University Teaching Hospital between April 1999 to April 2003, to asses the maternal and perinatal outcome of acute hepatitis E in pregnancy. During this period a total of 19 patients presented with jaundice. Out of 19 cases, 16 suffered from acute hepatitis due to hepatitis E. Acute hepatitis was diagnosed by presence of prodromal symptoms and anti HEV IgM in the body. Hepatitis B and C were ruled out in all these cases. Out of 16, 15 delivered in the hospital. Average age of the patients was 24 years. 81.2% (13/16) presented during the third trimester of pregnancy. There were 3 maternal deaths (20%). Other complications were; Preterm delivery 53.3% (8/15), post partum haemorrhage 26.7% (4/15), low birth weight in 33.3% (5/15). This analysis showed increased maternal and perinatal complications of hepatitis E contracted during pregnancy, especially so in those with fulminant hepatitis.

Two Cases of Acute Hepatitis E in Patients with Hyperthyroidism / 대한소화기학회지

Acute hepatitis E occur commonly as outbreaks in endemic areas, but can occur sporadically in other part of the world. Acute hepatitis E has been reported rarely in Korea. A case of concurrent acute hepatitis E virus (HEV) infection and hyperthyroidism was reported in an inactive hepatitis B surface antigen carrier. We experienced two cases of concomitant acute HEV infection in patients with hyperthyroidism. The first case had acute HEV infection with subclinial hyperthyroidism while taking propylthiouracil. The second case suffered from acute HEV infection in a patient with Graves' disease intractable to propylthiouracil. Herein, we suggest the possible association between HEV infection and hyperthyroidism.

Guillain-Barre syndrome associated with acute hepatitis E.

A 58-year-old woman presented with a brief icteric illness followed by progressive bilateral symmetrical hypotonic areflexic muscular weakness and unilateral infranuclear facial palsy. She was diagnosed to be suffering from Guillain-Barre syndrome and acute hepatitis E. Such an association has not been described till date.

Acute viral E hepatitis with chronic liver disease (autoimmune hepatitis).

A 36 years old male presented with anorexia, jaundice and ascites. He was suffering from acute viral E hepatitis. In view of ascites, he was investigated for associated asymptomatic chronic liver disease (CLD). The CLD was diagnosed as cirrhosis with autoimmune hepatitis and was treated with steroid with good response. He is maintaining good health with low dose steroid, on follow up for 1 year.

Acute pancreatitis associated with acute hepatitis E infection.

A 45-year-old male presented with severe abdominal pain, hyperamylasaemia and a bulky pancreas. In addition, he had deep jaundice and markedly raised serum transaminases, and his serum was positive for IgM anti-hepatitis E virus (HEV) antibodies. The common aetiologies of acute pancreatitis were excluded. The patient ran a benign course for both acute viral hepatitis and acute pancreatitis, and recovered completely. Acute pancreatitis caused by HEV infection has been reported only occasionally.

Acute liver failure.

Acute liver failure in children is associated with a high mortality. Most cases in our setup are due to water borne hepatotropic viruses HAV and HEV. The clinician must be aware of the earliest and the subtle signs of acute liver failure to identify cases early enough and institute supportive therapy. Focus of therapy has to be on prevention, early recognition and appropriate management of complications. Despite good intensive care, about 40-60% children with liver failure die. As and when liver transplantation becomes available in India, it would be an attractive option.