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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 16% 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 hepatitis E virus (HEV) genotype 3 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

    • Thyroiditis

    • Myocarditis

    • Glomerulonephritis

    • Monoclonal gammopathy

    • Thrombocytopenia

    • Aplastic anemia

    • Neurologic complications, including Guillain-Barré syndrome and neuralgic amyotrophy (which involves the brachial plexuses bilaterally)

    • Hemophagocytic lymphohistiocytosis

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


  • Hepatitis E antibodies

    • Anti-HEV IgM is positive in acute hepatitis E

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


  • 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

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