Gauss et al. Journal of Medical Case Reports 2012, 6:334 http://www.jmedicalcasereports.com/content/6/1/334 HEV genotype 3 strains. Sporadic cases have been reported in France and other countries [7-9]. Only a few reports on zoonotic HEV infections in Germany exist [10]. Interestingly, recent reports demonstrate a surprisingly high HEV seroprevalence in German domestic pig stocks [11] and in humans with occupational exposure to pigs [12]. HEV-specific ribonucleic acid (RNA) was detected in porcine livers in southeastern Germany with high se- quence homology to human HEV isolates [13]. Given these data, it is tempting to speculate that zoonotic and alimentary transmission routes play a role in sporadic human HEV cases, but the detailed mode of transmission is still not well understood. The subject of our report is a rare case of chronic HEV in an immunosuppressed patient with B-cell chronic lymphocytic leukemia (B-CLL). Case presentation A 46-year-old Caucasian man who worked as a mechanic was transferred to the gastroenterology out-patient clinic Page 2 of 5 by the department of hematology, where he was regularly treated for B-CLL. The reason for the visit was a continu- ous increase of transaminases over the previous 7 months (months 0 to 7). The patient reported persistent exhaus- tion and occasional right-side abdominal pain. B-CLL had been diagnosed 4 years earlier (initially Binet stage B; ac- tual blood cell counts: leukocytes 13.6/nL, thrombocytes 224/nL, and hemoglobin 16.3g/dL). Owing to increasing night sweats and compression of the urinary bladder by lymphomas 2 years earlier (leukocyte count 61/nL), he was treated with rituximab, pentostatin, and cyclophos- phamide for 3 months, resulting in partial remission. Maintenance therapy was performed by using rituximab and was finally abandoned in month 4 of increased transa- minases because of severe fatigue and susceptibility to infections, after which the patient took no medication. At the time of referral to our department, the patient was in stable partial remission and B symptoms were absent. He had no history of recent travels to countries outside Figure 1 Course of alanine transaminase and hepatitis E virus ribonucleic acid (HEV RNA) levels in the patient’s blood related to time indicated in months (M). Intervals and types of chronic lymphocytic leukemia therapy are shown. The time scale on the x-axis is related to time point “0 M”, when elevated transaminase concentrations were measured for the first time. This was also the time point at which rituximab was administered for the last time. The diagnosis of HEV infection by positive HEV polymerase chain reaction was first made at 6.5 months; HEV RNA concentrations at 0 and 5.25 months were measured retrospectively. Unfortunately, no earlier samples were available to show when HEV RNA first appeared in the blood.