Gauss et al. Journal of Medical Case Reports 2012, 6:334 http://www.jmedicalcasereports.com/content/6/1/334 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Chronic hepatitis E virus infection in a patient with leukemia and elevated transaminases: a case report Annika Gauss1†, Juergen J Wenzel2†, Christa Flechtenmacher3, Mojdeh Heidary Navid4, Christoph Eisenbach1, Wolfgang Jilg2, Wolfgang Stremmel1 and Paul Schnitzler4* Abstract Introduction: Acute hepatitis E virus infection may cause mild, self-limiting hepatitis, either as epidemic outbreaks or sporadic cases, the latter of which have been reported in industrialized countries. Chronic infections are uncommon and have been reported in immunosuppressed patients, patients with human immunodeficiency virus infection, and patients with hematological malignancies. Case presentation: A 46-year-old Caucasian man was admitted to the gastroenterology clinic with a history of increasing transaminases, persistent exhaustion, and occasional right-side abdominal pain over the course of a 6-month period. B-cell chronic lymphocytic leukemia had been diagnosed several years earlier, and the patient was treated with rituximab, pentostatin, and cyclophosphamide. A diagnostic workup ruled out autoimmune and metabolic liver disease, hepatitis A-C, and herpes virus infection. A physical examination revealed enlarged axillary lymph nodes. The results of an abdominal ultrasound examination were otherwise unremarkable. Hepatitis E virus infection was diagnosed by detection of hepatitis E virus-specific antibodies. Blood samples were positive for hepatitis E virus ribonucleic acid with high viral loads for at least 8 months, demonstrating a rare chronic hepatitis E virus infection. Sequencing and phylogenetic analysis revealed hepatitis E virus genotype 3c with homologies to other European isolates from humans and swine, indicating an autochthonous infection. Conclusions: Usually, hepatitis E virus infection appears as an acute infection; rare chronic infections have been reported for transplant patients, patients with human immunodeficiency virus, and patients with hematological malignancies. The chronic nature of hepatitis E infection in our patient was most likely induced by the immunosuppressive B-cell chronic lymphocytic leukemia treatment. The differential diagnosis in patients with unexplained hepatitis should include hepatitis E virus infection, and appropriate laboratory analyses should be considered. Keywords: Hepatitis E virus, Chronic hepatitis, Autochthonous hepatitis E Introduction Signs and symptoms of hepatitis E virus (HEV) infection comprise jaundice, elevated transaminases, nausea, vomit- ing, myalgia, abdominal pain, and fever. In some cases, HEV infection may result in acute liver failure. The overall disease mortality is low, but fulminant hepatitis is frequent among pregnant women in HEV-endemic regions. * Correspondence: paul_schnitzler@med.uni-heidelberg.de †Equal contributors 4Department of Infectious Diseases, Virology, University of Heidelberg, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany Full list of author information is available at the end of the article Chronic hepatitis with persistent viral replication has been reported among transplant recipients infected shortly after transplantation [1,2]. Moreover, reports about chronic HEV infections in patients with concomitant human im- munodeficiency virus (HIV) infection and patients with hematological malignancies have been published [3-5]. Epidemic outbreaks in developing countries are typically caused by HEV genotype 1 strains which are transmitted from human to human via the fecal-oral route [6]. In con- trast, sporadic HEV cases in industrialized countries are most likely of zoonotic origin and usually are caused by © 2012 Gauss et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.