Chronic hepatitis E: a review of the literature

Hepatitis E Virus in Pork and Variety Meats Sold in Fresh Markets

Swine is an economically important livestock, yet pork consumption and close contact with pigs are associated with the risk of hepatitis E virus (HEV) infection. Limited data on the prevalence of HEV in Southeast Asia have mainly examined farm animals. To investigate the potential zoonotic transmission of HEV from dietary consumption of pork and variety meats (i.e., offal or organ meats), we obtained 1090 liver, 559 pork meat, and 556 intestine samples from fresh markets in the Bangkok metropolitan area between November 2014 and February 2015. The presence of HEV was assessed using reverse-transcription polymerase chain reaction. Concurrently, 720 bile and 553 fecal samples from a slaughterhouse were also examined. Overall, HEV RNA was found in 0.23 % of the market samples and 3.93 % of the slaughterhouse samples. Fecal and bile samples were more likely to test positive compared to liver, pork, and intestine samples (p < 0.001). Phylogenetic analysis showed that all HEV sequences obtained in this study formed a cluster closely related to genotype 3f. Pork and variety meats derived from pigs are commonly sold in fresh markets throughout Southeast Asia. Here, a relatively low HEV prevalence from pork and variety meats sold in Bangkok was found. Additional studies will be required to further assess potential dietary transmission of HEV elsewhere in the region.

Acute hepatitis E mimicking a flare of disease in a patient with chronic autoimmune hepatitis

 Acute hepatitis E is becoming increasingly recognised in Europe with up to 40% of the population in Southern France being exposed to the virus, which is harboured in pigs. Patients with known liver disease may present with acute hepatitis E and present a diagnostic challenge. For example patients with autoimmune hepatitis (AIH) who are immunosuppressed and contract hepatitis E may be at increased risk of developing chronicity due to concurrent immunosuppression. Importantly, the diagnosis may be missed with the infection misdiagnosed as an autoimmune flare, and immunosuppression increased by the attending physician, thus enhancing the risk of chronicity of infection leading to progressive liver injury in immunocompromised patients. We report a case of acute hepatitis E in a patient with AIH and discuss the features that helped us differentiating it from an autoimmune flare.

Hepatitis E Virus in Industrialized Countries: The Silent Threat

Hepatitis E virus (HEV) is the main cause of acute viral hepatitis worldwide. Its presence in developing countries has been documented for decades. Developed countries were supposed to be virus-free and initially only imported cases were detected in those areas. However, sporadic and autochthonous cases of HEV infection have been identified and studies reveal that the virus is worldwide spread. Chronic hepatitis and multiple extrahepatic manifestations have also been associated with HEV. We review the data from European countries, where human, animal, and environmental data have been collected since the 90s. In Europe, autochthonous HEV strains were first detected in the late 90s and early 2000s. Since then, serological data have shown that the virus infects quite frequently the European population and that some species, such as pigs, wild boars, and deer, are reservoirs. HEV strains can be isolated from environmental samples and reach the food chain, as shown by the detection of the virus in mussels and in contaminated pork products as sausages or meat. All these data highlight the need of studies directed to control the sources of HEV to protect immunocompromised individuals that seem the weakest link of the HEV epidemiology in industrialized regions.

Systematic identification of hepatitis E virus ORF2 interactome reveals that TMEM134 engages in ORF2-mediated NF-κB pathway

Hepatitis E virus (HEV) is the causative agent of acute hepatitis E. Open reading frame 2 (ORF2) encodes the capsid protein of HEV, which is the main structural protein and may participate, together with the host factors, in viral entry and egress. However, it is still not clear which host proteins are involved in the interaction with ORF2 and what the functions of these ORF2-interacting proteins are. In this study, we have applied a split-ubiquitin yeast two-hybrid screening approach in combination with the pull-down and coimmunoprecipitation assays, identified and validated multiple interacting partners of ORF2 of genotype 1 and 4, which have diverse biological functions. Among these novel candidates that have not been previously reported, we have found that 20 of them are located in endoplasmic reticulum. TMEM134, which interacts and co-localizes with ORF2 in the endoplasmic reticulum, negatively regulates ORF2-mediated inhibition of the NF-κB signaling pathway. Our study for the first time has systematically mapped the ORF2 interactome in two genotypes of HEV, providing a new insight of understanding the virus-host interaction during the pathogenesis of HEV, and may offer potential therapeutic targets to intervene the HEV life cycle.

Epidemiology of Hepatitis E in Pregnant Women and Children in Iran: A General Overview

From an epidemiological point of view, hepatitis E is an old infection in Iran, but only recently has its importance as a public health concern been considered from research and public health standpoints. As such, there is still a long road ahead to clarify the real burden of hepatitis E virus (HEV) infection in Iran. According to the available epidemiological studies, the seroprevalence of HEV infection among pregnant women is between 3.6% and 7.4%, and among Iranian children is between 0.9% to 8.5%, varying by geographic regions within the country and directly dependent upon the sanitary status of each. In addition to evaluating the sanitation level of a society, community-based seroprevalence studies of HEV infection demonstrate the most prevalent risk factors, the major routes of transmission, and the epidemiological patterns of HEV among that country's population. In this review, the current knowledge about the pathogenesis and epidemiology of HEV infection in pregnant women and children in Iran, as well as the recent advances in diagnosis, prevention and treatment of HEV infection have been summarized.

The mystery of the Hawaii liver disease cluster in summer 2013: A pragmatic and clinical approach to solve the problem

BACKGROUND AND AIM

In the fall of 2013, the US Centers for Disease Control and Prevention (CDC) published a preliminary report on a cluster of liver disease cases that emerged in Hawaii in the summer 2013. This report claimed a temporal association as sufficient evidence that OxyELITE Pro (OEP), a dietary supplement (DS) mainly for weight loss, was the cause of this mysterious cluster. However, the presented data were inconsistent and required a thorough reanalysis.

MATERIAL AND METHODS

To further investigate the cause(s) of this cluster, we critically evaluated redacted raw clinical data of the cluster patients, as the CDC report received tremendous publicity in local and nationwide newspapers and television. This attention put regulators and physicians from the medical center in Honolulu that reported the cluster, under enormous pressure to succeed, risking biased evaluations and hasty conclusions.

RESULTS

We noted pervasive bias in the documentation, conclusions, and public statements, also poor quality of case management. Among the cases we reviewed, many causes unrelated to any DS were evident, including decompensated liver cirrhosis, acute liver failure by acetaminophen overdose, acute cholecystitis with gallstones, resolving acute hepatitis B, acute HSV and VZV hepatitis, hepatitis E suspected after consumption of wild hog meat, and hepatotoxicity by acetaminophen or ibuprofen. Causality assessments based on the updated CIOMS scale confirmed the lack of evidence for any DS including OEP as culprit for the cluster.

CONCLUSIONS

Thus, the Hawaii liver disease cluster is now best explained by various liver diseases rather than any DS, including OEP.

Hepatitis E virus mutations associated with ribavirin treatment failure result in altered viral fitness and ribavirin sensitivity

BACKGROUND & AIMS

Ribavirin monotherapy is the preferred treatment for chronic hepatitis E, although occasional treatment failure occurs. We present a patient with chronic hepatitis E experiencing ribavirin treatment failure with a completely resistant phenotype. We aimed to identify viral mutations associated with treatment failure and explore the underlying mechanisms.

METHODS

Viral genomes were deep-sequenced at different time points and the role of identified mutations was assessed in vitro using mutant replicons, antiviral assays, cell culture of patient-derived virus and deep-sequencing.

RESULTS

Ribavirin resistance was associated with Y1320H, K1383N and G1634R mutations in the viral polymerase, but also an insertion in the hypervariable region comprising a duplication and a polymerase-derived fragment. Analysis of these genome alterations in vitro revealed replication-increasing roles for Y1320H and G1634R mutations and the hypervariable region insertion. In contrast, the K1383N mutation in the polymerase F1-motif suppressed viral replication and increased the in vitro sensitivity to ribavirin, contrary to the clinical phenotype. Analysis of the replication of mutant full-length virus and in vitro culturing of patient-derived virus confirmed that sensitivity to ribavirin was retained. Finally, deep-sequencing of hepatitis E virus genomes revealed that ribavirin is mutagenic to viral replication in vitro and in vivo.

CONCLUSIONS

Mutations Y1320H, G1634R and the hypervariable region insertion compensated for K1383N-associated replication defects. The specific role of the K1383N mutation remains enigmatic, but it appears to be of importance for the ribavirin resistant phenotype in this patient.

LAY SUMMARY

Ribavirin is the most common treatment for chronic hepatitis E and is mostly effective, although some cases of ribavirin treatment failure have been described. Here, we report on a particular case of ribavirin resistance and investigate the underlying causes of treatment failure. Mutations in the viral polymerase, an essential enzyme for viral replication, appear to be responsible.

Hepatitis E: Discovery, global impact, control and cure

Hepatitis E was identified as an epidemic of non-A, non-B hepatitis from Kashmir, India in 1978. Hepatitis E virus (HEV), the etiological agent is the sole member of family Hepeviridae. The virus has marked heterogeneity and infects many animals like bats, camel, chicken, deer, boar, mongoose, pigs, rats, rabbit and cutthroat trout. Hepatitis E is a disease with a major global impact and has two distinct epidemiological patterns. Hepatitis E is an imperative health issue in developing nations, transmitted through sullied water and happens most every now in young adults. The disease is particularly severe during pregnancy and in people with underlying liver cirrhosis. Autochthonous hepatitis E is increasingly recognized in developed countries. The virus infects domestic pigs, wild boar and Sika deer in these countries. HEV infections in humans occur by eating the undercooked game flesh, raw liver from supermarkets and Figatelli sausages. Blood transfusion-associated HEV infections occur in many countries and screening of donors for HEV RNA is under consideration. Hepatitis E causes a number of extrahepatic diseases, including a wide spectrum of neurological syndromes. HEV genotype 3 causes prolonged viremia, chronic hepatitis, liver fibrosis and cirrhosis in organ transplant patients. The virus is amenable to ribavirin monotherapy and most patients clear the virus in a few weeks. Hepatitis E vaccine -239, marketed in China, has shown high efficacy with sustained protection for over four years.

Chronic hepatitis E - an emerging disease in an immunocompromised host

Chronic hepatitis E virus (HEV) infection is increasingly being reported in immunosuppressed individuals with HIV, patients with haematological malignancy and transplant recipients. The diagnosis of cirrhosis and liver failure post chronic HEV is controversial due to lack of standard diagnostic criteria. The treatment benefits of ribavirin in chronic HEV of genotype 1 are not well reported. We report a case of chronic HEV infection of genotype 1 leading to chronic liver disease in a child cured of acute leukaemia. Our report also highlights the successful use of ribavirin for eradicating chronic HEV infection and its subsequent survival benefits. Chronic hepatitis E may be an emerging disease of immunosuppressed patients and should be suspected in the presence of cryptogenic transaminitis. Ribavirin is an effective therapy for controlling HEV.

High prevalence of anti-hepatitis E virus antibodies among blood donors in central Italy, February to March 2014

Prevalence of anti-hepatitis E virus (HEV) antibodies is highly variable in developed countries, which seems partly due to differences in assay sensitivity. Using validated sensitive assays, we tested 313 blood donors attending a hospital transfusion unit in central Italy in January and February 2014 for anti-HEV IgG and IgM and HEV RNA. Data on HEV exposure were collected from all donors. Overall anti-HEV IgG prevalence was 49% (153/313). Eating raw dried pig-liver sausage was the only independent predictor of HEV infection (adjusted prevalence rate ratio = 2.14; 95% confidence interval: 1.23–3.74). Three donors were positive for either anti-HEV IgM (n = 2; 0.6%) or HEV RNA (n = 2; 0.6%); they were completely asymptomatic, without alanine aminotransferase (ALT) abnormalities. Of the two HEV RNA-positive donors (both harbouring genotype 3), one was anti-HEV IgG- and IgM-positive, the other was anti-HEV IgG- and IgM-negative. The third donor was positive for anti-HEV IgG and IgM but HEV RNA-negative. HEV infection is therefore hyperendemic among blood donors (80% men 18–64 years-old) from central Italy and associated with local dietary habits. Nearly 1% of donors have acute or recent infection, implying potential transmission to blood recipients. Neither ALT nor anti-HEV IgM testing seems useful to prevent transfusion-transmitted HEV infection.

Increased Hepatitis E Virus Seroprevalence Correlates with Lower CD4+ Cell Counts in HIV-Infected Persons in Argentina

Hepatitis E virus (HEV) is a single-stranded RNA virus that can cause hepatitis in an epidemic fashion. HEV usually causes asymptomatic or limited acute infections in immunocompetent individuals, whereas in immunosuppressed individuals such as transplant recipients, HEV can cause chronic infections. The risks and outcomes of HEV co-infection in patients infected with human immunodeficiency virus (HIV) are poorly characterized. We used a third generation immunoassay to measure serum IgG antibodies specific for HEV in 204 HIV-infected individuals from Argentina and a control group of 433 HIV-negative individuals. We found 15 of 204 (7.3%, 95%CI 3.74-10.96%) individuals in the HIV-positive group to have positive HEV IgG levels suggestive of previous infection, compared to 19 of 433 (4.4%, 95% CI 2.5-6.3%) individuals in the HIV-negative control group (p = 0.12). Among HIV-positive individuals, those with HEV seropositivity had lower CD4 counts compared to those that were HEV seronegative (average CD4 count of 234 vs 422 mm3, p = 0.01), indicating that patients with lower CD4 counts were more likely to be HEV IgG positive. Moreover, HEV seropositivity in patients with CD4 counts <200 mm3 was 16%, compared to 4.5% in those with CD4 counts >200 mm3 (p = 0.012). We found a positive PCR result for HEV in one individual. Our study found that increased seroprevalence of HEV IgG correlated with lower CD4 counts in HIV-infected patients in Argentina.

Epidemiology of hepatitis E virus in Iran

Iran is known as an endemic country for hepatitis E virus (HEV) infection, while there are variations in the epidemiology of HEV infection throughout the country. The available epidemiological studies in different regions of Iran show HEV seroprevalence of 1.1%-14.2% among general population, 4.5% -14.3% among blood donors, 6.1%-22.8% among injecting drug users, 6.3%-28.3% among hemodialysis patients, 1.6%-11.3% among patients infected with other hepatitis viruses, 27.5% among patients with chronic liver disease, 30.8% among kidney transplant recipient patients, and 10%-16.4% among human immunodeficiency virus-infected patients. These variations reflect differences in the status of public health and hygiene, risk factors, and routes of transmission in different regions and groups. Therefore, it is necessary to review the epidemiology of HEV infection to determine the most prevalent risk factors and routes of transmission, and to evaluate the effectiveness of preventive strategies employed in the public health services of the country. Moreover, the other epidemiological aspects of HEV, including the genotypic pattern, extra hepatic manifestations, and incidence of chronic infection need to be investigated among Iranian population to expand the current knowledge on the epidemiology of HEV and to clarify the real burden of HEV infection. Therefore, this review was performed to provide a general overview regarding the epidemiology of HEV in Iran.

Hepatitis E virus infection in the HIV-positive patient

Hepatitis E virus (HEV) is a RNA virus that can cause hepatitis. In immunocompetent individuals, infection with HEV usually leads to asymptomatic seroconversion. However, in immunosuppressed patients, such as transplant recipients, HEV can develop into a chronic infection. Studies regarding the seroprevalence and clinical implications of HEV in patients infected with the human immunodeficiency virus (HIV) are conflicting. Levels of CD4 count in blood seem to be the most widely associated risk factor, while other factors such as meat consumption or proximity to animals are less clearly associated with HEV infection. Progression to chronicity, as well as extrahepatic manifestations of HEV seem rare in HIV, and the implications of HEV in liver disease progression are poorly understood in the HIV-infected. In this review we describe the epidemiology, risk factors, and clinical implications of HEV infection in individuals infected with HIV.

Identification of Distribution Characteristics and Epidemic Trends of Hepatitis E in Zhejiang Province, China from 2007 to 2012

Hepatitis E virus is a common hepatotropic virus that causes serious gastrointestinal symptoms. Data of reported HEV cases in Zhejiang Province was collected between 2007 and 2012. Descriptive epidemiological methods and spatial-temporal epidemiological methods were used to investigate the epidemiological trends and identify high-risk regions of hepatitis E infection. In this study, the average morbidity of hepatitis E infection was 4.03 per 100,000 in Zhejiang Province, peaking in winter and spring. The ratio between the male and the female was 2.39:1, and the high-risk population was found to be aged between 40 and 60. Trend surface analysis and IDW maps revealed higher incidences in the northwestern counties. The spatial-temporal analysis showed comparable incidences in the counties at the basins of three rivers, mostly under administration of Hangzhou Municipality. Besides, the seasonal exponential smoothing method was determined as the better model for the retrieved data. The epidemiological characteristics of HEV suggested the need of strengthened supervision and surveillance of sanitary water, sewage treatment and food in high-risk areas especially around the Spring Festival. Additionally, time series model could be useful for forecasting the epidemics of HEV in future. All these findings may contribute to the prevention and control of HEV epidemics.

Antiviral Activities of Different Interferon Types and Subtypes against Hepatitis E Virus Replication

Hepatitis E virus (HEV) is the causative agent of hepatitis E in humans and a member of the genusOrthohepevirusin the familyHepeviridae HEV infections are the common cause of acute hepatitis but can also take chronic courses. Ribavirin is the treatment of choice for most patients, and type I interferon (IFN) has been evaluated in a few infected transplant patientsin vivo In this study, the antiviral effects of different exogenously administered interferons were investigated by using state-of-the-art subgenomic replicon and full-length HEV genome cell culture models. Hepatitis C virus (HCV) subgenomic replicons based on the genotype 2a JFH1 isolate served as the reference. The experiments revealed that HEV RNA replication was inhibited by the application of all types of IFN, including IFN-α (type I), IFN-γ (type II), and IFN-λ3 (type III), but to a far lesser extent than HCV replication. Simultaneous determination of interferon-stimulated gene (ISG) expression levels for all IFN types demonstrated efficient downregulation by HEV. Furthermore, different IFN-α subtypes were also able to block viral replication in combination with ribavirin. The IFN-α subtypes 2a and 2b exerted the strongest antiviral activity against HEV. In conclusion, these data demonstrate for the first time moderate anti-HEV activities of types II and III IFNs and different IFN-α subtypes. As HEV employed a potent anti-interferon mechanism by restricting ISG expression, exogenous application of IFNs as immunotherapy should be carefully assessed.

The Honolulu Liver Disease Cluster at the Medical Center: Its Mysteries and Challenges

In 2013, physicians at the Honolulu Queen’s Medical Center (QMC) noticed that seven liver disease patients reported the use of OxyELITE Pro (OEP), a widely consumed dietary supplement (DS). Assuming a temporal association between OEP use and disease, they argued that OEP was the cause of this mysterious cluster. Subsequent reexamination, however, has revealed that this QMC cohort is heterogeneous and not a cluster with a single agent causing a single disease. It is heterogeneous because patients used multiple DS’s and drugs and because patients appeared to have suffered from multiple liver diseases: liver cirrhosis, liver failure by acetaminophen, hepatotoxicity by non-steroidal antiinflammatory drugs (NSAIDs), resolving acute viral hepatitis by hepatitis B virus (HBV), herpes simplex virus (HSV), and varicella zoster virus (VZV), and suspected hepatitis E virus (HEV). Failing to exclude these confounders and to consider more viable diagnoses, the QMC physicians may have missed specific treatment options in some of their patients. The QMC physicians unjustifiably upgraded their Roussel Uclaf Causality Assessment Method (RUCAM) causality scores so that all patients would appear to be “probable” for OEP. However, subsequent RUCAM reassessments by our group demonstrated a lack of causality for OEP in the evaluated QMC cases. The QMC’s questionable approaches explain the extraordinary accumulation of suspected OEP cases at the QMC in Hawaii as single place, whereas similar cohorts were not published by any larger US liver center, substantiating that the problem is with the QMC. In this review article, we present and discuss new case data and critically evaluate upcoming developments of problematic regulatory assessments by the US Centers for Disease Control and Prevention (CDC), the Hawaii Department of Health (HDOH), and the Food and Drug Administration (FDA), as based on invalid QMC conclusions, clarifying now also basic facts and facilitating constructive discussions.

Hepatitis A Virus and Hepatitis E Virus Seroprevalence Among Blood Donors in Tehran, Iran

BACKGROUND

Hepatitis A virus (HAV) and Hepatitis E virus (HEV) are both transmitted by the fecal-oral route and are known as the leading causes of acute viral hepatitis in the world, especially in developing countries. There is a lack of updated data on HAV and HEV seroprevalence in Iran.

OBJECTIVES

The aim of this study was to determine the seroprevalence of HAV and HEV among a group of blood donors in Tehran, Iran.

MATERIALS AND METHODS

A cross-sectional study was performed from July 2014 to December 2014, on a total of 559 blood donors referred to the Tehran blood transfusion center. The serum samples were tested for antibodies to HAV and HEV, using the enzyme-linked immunosorbent assay.

RESULTS

In the present study, 536 (95.9%) cases were male and 23 (4.1%) female with mean age of 38 years. Out of 559 blood donors, 107 (19.1%) were first-time donors, 163 (29.2%) lapsed donors and 289 (51.7%) regular donors. Anti-HAV was found in 395 (70.7%) and anti-HEV in 45 (8.1%) of the blood donors. The HAV and HEV seroprevalence increased by age. There was no significant difference between genders in terms of anti-HAV and anti-HEV status. The HAV and HEV seroprevalence was significantly related to the level of education, where the donors with higher level of education had lower rate of HAV and HEV seroprevalence. The HAV and HEV seroprevalence was significantly higher in regular and lapsed donors than in first-time donors.

CONCLUSIONS

The present study showed that both HAV and HEV infections are still endemic in Iran.

Full coding hepatitis E virus genotype 3 genome amplification method

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A new amplification method for the complete HEV coding genome was described.

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HEV genome organization and function were reviewed.

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Polymorphic amino acids of each HEV genome region were analyzed in reference sequences.

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Complete coding HEV sequence of an immunocompromised patient with acute infection was analyzed.

Hepatitis E virus (HEV) genotype 3 produces zoonotic infection associated with the consumption of infected animals. HEV infections can become chronic in immunocompromised (IC) patients. The viral genome has three well defined open reading frames (ORF1, ORF2 and ORF3) within which various domains and functions have been described. This paper (i) describes a new method of complete sequencing of the HEV coding region through overlapping PCR systems, (ii) establishes a consensus sequence and polymorphic positions (PP) for each domain, and (iii) analyzes the complete coding sequence of an IC patient. With regard to the consensus, a high percentage of PP was observed in protease (PP = 19%) and the X domain (PP = 22%) within ORF1, the N-terminal region of the S domain (PP = 22%) in ORF2, and the P1 (PP = 35%) and P2 (PP = 25%) domains in ORF3. In contrast, the ORF1 Y, ORF2 S, ORF2 M and ORF3 D1 domains were conserved in the reference sequences (0.40, 1, 0.70 and 0% of PP, respectively). The sequence from the IC patient had more mutations in the RpRp (D1235G, Q1242R, S1454T, V1480I, I1502 V, K1511R, G1373 V, E1442D, V1693 M), the terminal ORF2 S- domain (F10L, S26T, G36S, S70P, A105 V, I113 V), the X domain (T938 M, T856 V, S898A) and the helicase (S1014N, S975T, Q1133 K).

Antiviral therapy in chronic hepatitis E: a systematic review

Hepatitis E viral infection can lead to a chronic infection in immunocompromised patients, resulting in progressive liver disease and cirrhosis. Isolated cases have shown that treatment with ribavirin or pegylated interferon-α can result in viral eradication. This systematic review evaluated efficacy and safety of both treatments in chronic hepatitis E. A systematic literature search was performed on PubMed, Web of Science and clinicaltrials.gov for articles and abstracts. The keywords '"Hepatitis E" or HEV' AND 'ribavirin or Rebetol or Copegus' OR 'pegylated interferon OR peginterferon' were combined. The primary outcome was sustained viral response (SVR). Secondary endpoints include rapid viral response (RVR), relapse rates and side effects. Twenty-four studies matched our criteria, representing a total of 105 ribavirin-treated and 8 pegylated interferon-treated patients. The majority of patients had a solid organ transplant. Sixty-four per cent of ribavirin-treated patients achieved a SVR at 6 months after treatment cessation compared to 2/8 peginterferon-treated patients. Ribavirin was relatively well tolerated with the main side effect being anaemia, requiring dose reduction in 28% of patients. Peginterferon leads to acute transplant rejection in 2/8 patients. Ribavirin monotherapy appears to be an effective and safe treatment in all immunocompromised patients with chronic hepatitis E. The use of pegylated interferon in transplant patients may lead to transplant rejection and is not recommended. Therefore, ribavirin should be the antiviral treatment of choice in chronic hepatitis E.

Chronic hepatitis E in solid-organ transplantation: the key implications of immunosuppressants

PURPOSE OF REVIEW

Solid-organ recipients infected with hepatitis E virus (HEV) bear an extremely high risk of developing chronic hepatitis, although this virus only causes acute infection in the general population. Immunosuppressive medication universally used after transplantation to prevent organ rejection appears to be a main risk factor for developing chronic infection. This review aims to overview and emphasize the current clinical and experimental evidence regarding the key implications of immunosuppressants in chronic hepatitis E.

RECENT FINDINGS

Over 60% of organ recipients who are infected with HEV develop chronic hepatitis. Immunosuppressant treatment after transplantation was identified as a key risk factor. Therefore, dose reduction or even withdrawal of immunosuppressants is considered as the first intervention strategy to achieve viral clearance in these patients. Otherwise, ribavirin, as an off-label medication, is considered as an antiviral treatment, with compelling outcomes observed so far. Interestingly, in addition to a common immunosuppression property that can favour HEV infection in general, different types of immunosuppressants may exert differential impacts on the infection course in patients. Furthermore, potential interaction may exist between particular immunosuppressant and ribavirin. With the recent development of a cell culture system for HEV, experimental research has been initiated to investigate how immunosuppressive drugs interact with HEV infection.

SUMMARY

On the basis of the current evidence, it remains impossible to define an optimal immunosuppressive protocol for these HEV-infected patients. However, the realization of this clinical issue and the initiation of translational research using cell culture models of HEV have been represented as milestones in this field.

Hepatitis E virus infection presenting with paraesthesia

Hepatitis E virus infection is an emerging disease in developed countries. Acute and chronic infection has been reported, with chronic infection being increasingly reported in immunocompromised patients. Neurological disorders are an emerging manifestation of both acute and chronic hepatitis E virus infection. We report a 77-year-old female presented with paraesthesia and was found to have abnormal liver function tests. Serology was found to be positive for hepatitis E virus IgM, IgG and RNA. Liver function tests normalised after three weeks and her neurological symptoms completely resolved. To our knowledge, this is the first case in Scotland of hepatitis E virus presenting only with neurological symptoms.

Mystery of hepatitis e virus: recent advances in its diagnosis and management

Mysterious aspects of the long presumed to be well-known hepatitis E virus (HEV) have recently surfaced that distinguish it from other hepatotropic viruses. It is a cause of chronic hepatitis in immunosuppressed patients. It has human to human transmission through blood and mantains high seroprevalence in blood donors. HEV has also been found to occur more frequently in the West in those without a history of travel to endemic countries. It has varied extrahepatic manifestations and has multiple non-human reservoirs including pigs and rats. Considering these recent discoveries, it appears odd that HEV is not sought more frequently when working up acute and chronic hepatitis patients. The disease is particularly severe among pregnant women and has a high attack rate in young adults. What adds to its ambiguity is the absence of a well-established diagnostic criteria for its detection and that there is no specific antiviral drug for hepatitis E, except for isolated cases where ribavirin or pegylated interferon alpha has been used with occasional success. This review paper discusses the recent advances in the knowledge of the virus itself, its epidemiology, diagnostic approach and prevention, and the treatment options available.

High prevalence of antibodies against hepatitis E virus in HIV-infected patients with unexplained liver disease

OBJECTIVE

To look for evidence of hepatitis E virus (HEV) exposure in HIV-infected patients with unexplained elevations of liver stiffness (LS).

METHODS

Case-control study conducted in 31 HIV-infected patients with unexplained elevations of LS and in 31 HIV-controls with normal LS, matched by age, sex and CD4 cell-counts. Serum HEV antibodies were tested by two ELISA procedures and by Immunoblot. We defined exposure to HEV as the detection of serum HEV antibodies by at least one of the two ELISA assays, provided that it was confirmed by Immunoblot. A real-time PCR RNA assay was conducted in all plasma samples to identify subjects with active HEV infection.

RESULTS

Exposure to HEV was demonstrated, according to the criteria used in this study, in 9 (29%) of the cases, whereas it was shown in 5 (16%) of the controls (p=.3). Serum HEV RNA was detected in none of the controls and in only in one case. This patient had a documented chronic hepatitis E with progression to cirrhosis.

CONCLUSIONS

HEV antibodies are frequently found in HIV-infected patients with unexplained liver disease.

New foe treated with old guns - supportive role of steroids in the treatment of acute severe hepatitis E

Background

Autochthonous hepatitis E has been observed with growing incidence in industrialized countries. Hepatitis E virus infection causes an acute hepatitis with spontaneous resolution in the majority of cases. However, in individual cases, hepatitis E may lead to life-threatening acute liver failure. In this report, we describe a case of acute liver injury caused by an autochthonous hepatitis E that resolved under steroid treatment. To our knowledge, this is the first case report describing supportive steroid monotherapy for acute liver injury due to hepatitis E.

Case presentation

A 63-year-old Caucasian male presented with acute liver injury of unknown origin. After excluding the most prevalent causes of acute liver injury, liver histology revealed signs of immune-mediated toxic or drug-induced liver injury. Therefore, immunosuppressive treatment with prednisolone was started. After initialization of steroid treatment, polymerase chain reaction analyses of peripheral blood and liver tissue revealed an acute hepatitis E virus infection (genotype 3). Under sustained steroid treatment, acute liver injury improved and hepatitis E infection resolved.

Conclusion

Steroid treatment might be an option to prevent progress of life-threatening liver failure and liver transplantation in patients with hepatitis E-induced acute liver injury and high-grade inflammation.

High hepatitis E virus seroprevalence with absence of chronic infection in HIV-infected patients

BACKGROUND & AIMS

The seroprevalence of the hepatitis E virus (HEV) and its chronicity rate in the HIV-infected population has not been well established. As a result, the magnitude of this emerging disease in this population cannot be established.

METHODS

Prospective study that included HIV-infected patients followed up between September 2012 and May 2013. All included patients were tested for anti-HEV IgG/IgM. In patients with confirmed anti-HEV IgG/IgM positivity, RT-PCR was performed. In patients where HEV RNA was amplified, a second RT-PCR assay was performed 6 months later to identify transient or chronic HEV infections.

RESULTS

Eight hundred and ninety-four HIV-infected patients were enrolled in the study. Of these patients, 399 (44.6%) were monoinfected with HIV; 462 (51.6%) were co-infected with HIV/HCV; 12 (1.3%) were co-infected with HIV/HBV; and 21 (2.3%) were co-infected with HIV/HCV/HBV. In 88 patients, anti-HEV IgG/IgM was detected (seroprevalence: 9.8% [95% CI: 8.02%-11.9%]). In five patients (0.5%; 95% CI: 0.2%-1.2%), HEV RNA was detected; 5.7% (95% CI: 2.1%-12.1%) of the patients were anti-HEV IgG/IgM positive. None of these patients showed detectable HEV RNA six months later.

CONCLUSION

HEV infection is frequent in HIV-infected patients but developing a chronic HEV infection may be considered an uncommon liver disease in this population.

Lack of persistent hepatitis E virus infection as a cause for unexplained transaminase elevation in renal transplant recipients in India

BACKGROUND

Hepatitis E virus (HEV) infection is highly endemic in India, being the most common cause of acute hepatitis; however, no case of chronic infection has been reported. All the human isolates of HEV from India till date have belonged to genotype 1. In contrast, in non-endemic areas, genotype 3 is the most prevalent, and persistent HEV infection has been reported among solid-organ transplant recipients. Whether persistent infection occurs with genotype 1 HEV is unclear. We therefore looked for evidence of HEV infection among renal transplant recipients with elevated alanine transaminase (ALT).

METHODS

Renal transplant recipients receiving immunosuppressive therapy were screened for ALT levels, irrespective of time duration since renal transplant. For those with ALT levels equal to or exceeding 50 IU/mL on at least two occasions ≥3 weeks apart, serum was tested for HEV RNA using a sensitive real-time reverse transcription polymerase chain reaction assay. For those testing positive, HEV genotyping and follow up for duration of viral persistence were planned.

RESULTS

Of the 275 patients studied, 49 (17.8 %, 44 male, median age = 39.5 years) had elevated ALT levels (median = 62 [range = 50-477] IU/L). None of these 49 patients had detectable HEV RNA in the serum using an assay with detection sensitivity of 300 copies of RNA/mL of specimen.

CONCLUSION

Our data indicate that persistent HEV infection is an infrequent cause of ALT elevation in Indian renal transplant recipients who are receiving immunosuppressive drugs. This suggests that infection with genotype 1 HEV may have either no or low potential to cause persistent infection.

Transmission, diagnosis, and management of hepatitis E: an update

Hepatitis E virus (HEV) infection is an important public health concern in many developing countries, causing waterborne outbreaks as well as sporadic autochthonous hepatitis. HEV is mainly transmitted by the fecal–oral route in endemic areas through drinking of contaminated water. However, zoonotic transmission from animal reservoirs to humans has also been suggested. Three additional routes of HEV transmission have been proposed to occur: blood borne, human to human, and vertical transmission from mother to child. Acute HEV infection is usually diagnosed by detecting specific anti-HEV antibodies. However, the performance of the available assays in different settings is not optimal. Analysis of HEV ribonucleic acid in biologic specimens such as stools, serum, and liver biopsy by using nucleic acid amplification techniques is also employed. Nonetheless, additional consensus regarding the best technologies suitable for serosurveys and diagnosis of acute HEV infection is also needed. This review article summarizes the current status of HEV infection end epidemiology with particular emphasis in transmission, diagnosis, and clinical management.

Multiplex hydrolysis probe real-time PCR for simultaneous detection of hepatitis A virus and hepatitis E virus

Detection of hepatitis viral infections has traditionally relied on the circulating antibody test using the enzyme-linked immunosorbent assay. However, multiplex real-time PCR has been increasingly used for a variety of viral nucleic acid detections and has proven to be superior to traditional methods. Hepatitis A virus (HAV) and hepatitis E virus (HEV) are the major causes of acute hepatitis worldwide; both HAV and HEV infection are a main public health problem. In the present study, a one-step multiplex reverse transcriptase quantitative polymerase chain reaction assay using hydrolysis probes was developed for simultaneously detecting HAV and HEV. This novel detection system proved specific to the target viruses, to be highly sensitive and to be applicable to clinical sera samples, making it useful for rapid, accurate and feasible identification of HAV and HEV.

Hepatitis E in Australian HIV-infected patients: an under-recognised pathogen?

Background Hepatitis E virus (HEV) infection has been found to cause chronic hepatitis in HIV-infected patients. In Australia, where HEV is nonendemic, background seroprevalence is reportedly low but has not been evaluated in the HIV-infected population. The study aimed to assess the seroprevalence of HEV in a cohort of HIV-infected patients with normal liver function and in another group with biochemical hepatitis.

METHODS

Patients were selected from the Victorian HIV Blood and Tissue Storage Bank and stored plasma was tested. Positive HEV antibody specimens were examined for HEV RNA by polymerase chain reaction.

RESULTS

A total of 191 HIV patients were tested for HEV by serology. Eight of 100 (8%) HIV-infected patients with normal liver function and 4 of 91 (4.4%) of those with biochemical hepatitis had HEV antibodies. All four patients with abnormal liver function and positive HEV serology were coinfected with hepatitis C and were significantly more likely to have higher median alanine aminotransferase levels (382 vs 139UL(-1), P=0.01). HEV-positive patients with normal liver function were more likely to be born outside Australia (P=0.004). Two of four patients with biochemical hepatitis who were seropositive for HEV had detectable HEV RNA.

CONCLUSIONS

The seroprevalence of HEV in this Australian HIV-infected cohort is higher than the estimated background prevalence in the HIV-negative population. In patients coinfected with hepatitis C, the degree of alanine aminotransferase elevation was significantly worse. HEV may contribute to the development of abnormal liver function.