Hepatitis E

For further information, see CMDT Part 16-04: Acute Hepatitis C & Other Causes of Acute Viral Hepatitis

Key Features

• A major cause of acute hepatitis throughout Central and Southeast Asia, the Middle East, and North Africa, where it is responsible for waterborne hepatitis outbreaks

• Uncommon in the United States (although up to 20% of the population have antibodies to the virus) but should be considered in patients with acute hepatitis after a trip to an endemic area

• In rare cases, hepatitis E can be mistaken for drug-induced liver injury

• In other countries, it may be spread by swine

• Risk factors

  • Presence of a pet in the home

  • Consumption of undercooked organ meats or infected cow's milk

Clinical Findings

• Illness generally is self-limited (no carrier state)

• Instances of chronic hepatitis with rapid progression to cirrhosis have been reported in

  • Liver transplant recipients (particularly when tacrolimus rather than cyclosporine is used as the main immunosuppressant)

  • Persons with HIV infection or with preexisting liver disease or receiving cancer chemotherapy (albeit rarely)

• Extrahepatic manifestations include

  • Arthritis

  • Pancreatitis

  • Monoclonal gammopathy

  • Thrombocytopenia

  • Neurologic complications, including Guillain-Barré syndrome and peripheral neuropathy

  • Hemophagocytic lymphohistiocytosis

• The risk of hepatic decompensation is increased in patients with underlying chronic liver disease

Diagnosis

• Hepatitis E antibodies

  • Anti-HEV IgM is positive in acute hepatitis E

  • Anti-HEV IgG is positive in convalescence from hepatitis E

Treatment

• A 3-month course of oral ribavirin has been reported to induce sustained clearance of HEV RNA from the serum in 78% of patients with persistent HEV infection and may be considered in patients with severe acute hepatitis E

• Improved public hygiene reduces the risk of infection in endemic areas

• A recombinant vaccine (Hecolin, or HEV 329) is approved for use in China