Fatal outbreaks of jaundice in pregnancy and the epidemic history of hepatitis E. Epidemiol Infect. 2012;140:767-787. [PMID: 22273541 DOI: 10.1017/s0950268811002925]

Diagnosis of hepatitis E

Hepatitis E, caused by infection with hepatitis E virus (HEV), is a common cause of enterically-transmitted acute hepatitis in developing countries. Occasional cases of sporadic hepatitis E have been increasingly recognized in developed countries over the past decade. These cases differ from those in developing countries in being possibly caused by zoonotic transmission, often affecting people with a suppressed immune system and occasionally leading to persistent HEV infection. The commonly used tests for HEV infection include detection of IgM and IgG anti-HEV antibodies and detection of HEV RNA. IgM anti-HEV antibodies can be detected during the first few months after HEV infection, whereas IgG anti-HEV antibodies represent either recent or remote exposure. The presence of HEV RNA indicates current infection, whether acute or chronic. Although several diagnostic assays for anti-HEV antibodies are available, they have undergone fairly limited testing and often provide discordant results, particularly for IgG antibodies. Thus, although the available antibody assays might be useful for case diagnosis in areas with high disease endemicity, their use for case diagnosis in areas with low endemicity and for seroprevalence studies remains problematic. Improved validation of existing anti-HEV antibody assays or development of new assays with superior performance characteristics is urgently needed.

Evolution of the hepatitis E virus polyproline region: order from disorder

The hepatitis E virus (HEV) polyproline region (PPR) is an intrinsically unstructured region (IDR). This relaxed structure allows IDRs, which are implicated in the regulation of transcription and translation, to bind multiple ligands. Originally the nucleotide variability seen in the HEV PPR was assumed to be due to high rates of insertion and deletion. This study shows that the mutation rate is about the same in the PPR as in the rest of the nonstructural polyprotein. The difference between the PPR and the rest of the polyprotein is due to the higher tolerance of the PPR for substitutions at the first and second codon positions. With this higher promiscuity there is a shift in nucleotide occupation of these codons leading to translation of more cytosine residues: a shift that leads to more proline, alanine, serine, and threonine being encoded rather than histidine, phenylalanine, tryptophan, and tyrosine. This pattern of amino acid usage is typical of proline-rich IDRs. Increased usage of cytosine also leads to >22% of all amino acids in the PPR being prolines. Alignments of PPR sequences from HEV strains representing all genotypes indicate that all zoonotic isolates share an ancestor, and the carboxyl half of the PPR is more tolerant of mutations than the amino half. The evolution of HEV PPR, in contrast with that of the rest of the nonstructural polyprotein, is molded by pressures that lead toward increased proline usage with a corresponding decrease in the usage of aromatic amino acids, favoring formation of IDR structures.