Chronic hepatitis E virus infection beyond transplantation or human immunodeficiency virus infection
Authors: Christoph Höner zu Siederdissen, Sven Pischke, Jerome Schlue, Katja Deterding, Timo Hellms, Susanne Schuler-Lüttmann, Anke Schwarz, Michael P. Manns, Markus Cornberg, Heiner Wedemeyer
Journal: Hepatology (2013)

We read with interest the article entitled "Chronic hepatitis E in an immunocompetent patient: a case report" by Grewal et al.1 Persistence of hepatitis E is usually associated with impaired antiviral defense mechanisms. Therefore, it is not surprising to detect prolonged hepatitis E virus (HEV) viremia in individuals receiving medications, which interfere with immune responses, as described by Grewal et al.1 Here, we describe three additional cases of chronic HEV infections beyond transplantation or human immunodeficiency virus infection. All patients were evaluated for elevated liver enzymes of unknown origin. The first patient was a 29-year-old man with a history of granulomatosis with polyangiitis. He received immunosuppressive therapy with mycophenolate (1,500 mg daily) and prednisolone (7.5 mg daily) and tested HEV RNA positive in January 2013. Analysis of stored samples proved persistent infection for more than 1 year. The patient was treated with ribavirin (RBV) for 5 months. HEV RNA became negative and liver enzymes normalized. The second patient was a 34-year-old man with a history of retroperitoneal fibrosis, receiving prednisolone (6 mg daily) and sirolimus (4 mg daily). Analysis of HEV RNA in stored serum samples revealed positive results for at least 2 years, confirming the diagnosis of chronic hepatitis E (CHE). Treatment with RBV was initiated. Three months after treatment cessation HEV RNA was negative and liver enzymes were normal. The third patient was a 48-year-old man, in whom autoimmune hepatitis (AIH) was suspected by a liver histology showing mixed, mainly lymphoplasmacytic, infiltration (Fig. 1). However, no autoantibodies could be detected and immunoglobulin G levels were normal. Importantly, the patient did not receive immunosuppressive medication. Diagnostic workup of this case excluded HIV infection and revealed an undefined CD4 T-cell defect. Testing of stored serum samples revealed that the patient has been infected with HEV for more than 2 years. RBV therapy has been recently initiated. This case is in line with a previous description of CHE in a patient with an undefined immune defect.2 These three patients demonstrate the possibility of development of chronic HEV infection in patients with different conditions of immunosuppression without previous transplantation or underlying HIV infection. Christoph Höner zu Siederdissen, M.D.1 Sven Pischke, M.D.2 Jerome Schlue, M.D.3 Katja Deterding, M.D.1 Timo Hellms, M.D.1 Susanne Schuler-Lüttmann, M.D.4 Anke Schwarz, M.D.5 Michael P. Manns, M.D.1 Markus Cornberg, M.D.1 Heiner Wedemeyer, M.D.1 1Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany 2Department of Internal Medicine, University Hospital Eppendorf, Hamburg, Germany 3Institute for Pathology, Hannover Medical School, Hannover, Germany 4Institute for Medical Microbiology, University Hospital Münster, Münster, Germany 5Department of Nephrology, Hannover Medical School, Hannover, Germany