The Korean Journal of Hepatology 2011;17:323-327 http://dx.doi.org/10.3350/kjhep.2011.17.4.323 Case Report 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 Hee-Sup Kim 1 , Sook-Hyang Jeong1, Je-Hyuck Jang1, Hyung-Joon Myung1, Jin-Wook Kim 1 , Soo-Mee Bang1, Sang Hoon Song2, Haeryoung Kim 3 , and Hae Sun Yun4 1Departments of Internal Medicine, 2Laboratory Medicine, and 3Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; 4Division of Enteric and Hepatitis Viruses, Center for Infectious Diseases, Korea National Institute of Health, Seoul, Korea 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. (Korean J Hepatol 2011;17:323-327) Keywords: Hepatitis A virus; Genotype; Coinfection; Hemolytic anemia; Korea INTRODUCTION distributions; however, co-circulation of multiple genotypes or subgenotypes has been reported in some regions of Hepatitis A virus (HAV) remains an important causative world.3 agent of acute viral hepatitis, causing large outbreak or severe This report presents a peculiar coinfection hepatitis with cases of fulminant hepatitis with fatal outcomes. Acute the HAV genotype IA and IIIA, complicated by severe hepatitis A can be complicated by extrahepatic manifestations, autoimmune hemolytic anemia and prolonged cholestasis, including hemolytic anemia, aplastic anemia, acute renal along with coexistence of IgM anti-hepatitis E virus (HEV). failure, and acute reactive arthritis.1,2 We performed immunohistochemical staining of HAV antigen Although HAV displays only a single serotype, seven HAV and HEV antigen in the liver biopsy specimen, and genotypes have been identified: four genotypes (I, II, III and molecular detection of HAV RNA and HEV RNA in the VII) are of human origin, and other three (IV, V, VI) are of serial serum samples obtained from the patient. simian origin. HAV genotypes have unique geographic Received November 8, 2010; Revised July 12, 2011; Accepted July 26, 2011 Abbreviations: AIHA, autoimmune hemolytic anemia; anti-IgG, immunoglobulin G antibody; ALT, alanine aminotransferase; AST, aspartate aminotransferase; HAV, Hepatitis A virus; Hb, hemoglobin; HCV, Hepatitis C virus; HEV, Hepatitis E virus; HAV RNA, hepatitis A virus ribonucleic acid; HEV RNA, hepatitis E virus ribonucleic acid; IgM anti-HAV, immunoglobulin M antibody to hepatitis A virus; IgM anti-HBc, immunoglobulin M antibody to hepatitis B core antigen; IgM anti-HEV, immunoglobulin M antibody to hepatitis E virus; INR, international normalized ratio; γ-GT, gamma-glutamyl transpeptidase Corresponding author: Sook-Hyang Jeong Department of Internal Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam 463-707, Korea Tel. +82-31-787-7039, Fax. +82-31-787-7042, E-mail; jsh@snubh.org Copyright Ⓒ 2011 by The Korean Association for the Study of the Liver The Korean Journal of Hepatology∙pISSN: 1738-222X eISSN: 2093-8047