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Musa J, Rahman M, Siddik AB, Saliaj K, Ikram S, Kola I, Shoushtarizadeh A, Guy A, Mamica I, Rahman A, Ahsan E, Cobo A, Blanco R. Anterior interosseous nerve lession and distal myoclonus revealing a parsonage turner syndrome associated with hashimoto thyroiditys. Radiol Case Rep 2021; 16:3176-3181. [PMID: 34484514 PMCID: PMC8405926 DOI: 10.1016/j.radcr.2021.07.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/22/2021] [Accepted: 07/24/2021] [Indexed: 11/28/2022] Open
Abstract
Parsonage-Turner Syndrome (PTS), also known as brachial neuritis or neuralgic amyotrophy, is a rare disorder affecting 2 to 3 individuals per 100,000 each year. Abrupt onset shoulder pain, followed by motor weakness, paresthesia and hypoesthesia, is usually reported, lasting several months with variable recovery. The etiology of the disease may be idiopathic or triggered by an underlying autoimmune disease in genetically susceptible individuals. Our report addresses a unique case of Parsonage-Turner Syndrome in a patient suffering from concurrent Hashimoto Thyroiditis. A previously healthy A 22 year-old female was referred to the Department of Neurology after complaints of sudden-onset motor weakness in her left upper limb. On physical examination, the patient could not make an “Ok sign” with her thumb and distal phalanx or form a complete fist, revealing weakness within the anterior interosseous branch of the median nerve. Further testing with electromyography demonstrated muscular atrophy within the arm's anterior compartment, forearm, and triceps brachii of the posterior compartment. Additional imaging and physical examination were unremarkable, confirming our diagnosis of PTS. Furthermore, lab reports revealed elevated levels of anti-thyroglobulin and anti-thyroid peroxidase antibodies and our patient was concurrently diagnosed with Hashimoto's thyroiditis. This case aims to highlight the rare co-occurrence of Hashimoto's thyroiditis with Parsonage-Turner Syndrome in an otherwise healthy patient. A 2014 study published by Nugent et al. had also shed light on brachial neuritis in a patient suffering from autoimmune connective tissue disease, and through this case study, we hope to add to the growing literature regarding the correlation between PTS and autoimmune diseases. Symptoms of PTS can easily be misdiagnosed given its similarity to other peripheral neuropathies, and careful assessment and thorough understanding of the disease is required to successfully distinguish it from other neurological pathologies.
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Affiliation(s)
- Juna Musa
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Masum Rahman
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Samar Ikram
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ina Kola
- Department of Burns and Plastic Surgery, Mother Teresa University hospital center, Tirana, Albania
| | | | - Ali Guy
- Department of Physical Medicine and Rehabilitation, NY University, NY Medical center, NY, USA
| | | | - Abdur Rahman
- Department of Medicine, Life and Care Hospital, Dhaka, Bangladesh
| | - Eram Ahsan
- Stem Cell Therapy and Skeletal Regeneration Lab, Mayo Clinic, Rochester, MN
| | | | - Ruben Blanco
- Centro de Diagnóstico Por Imágenes Clínico Integral (CEDICLIN), Santiago, Dominican Republic
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Jha AK, Kumar G, Dayal VM, Ranjan A, Suchismita A. Neurological manifestations of hepatitis E virus infection: An overview. World J Gastroenterol 2021; 27:2090-2104. [PMID: 34025066 PMCID: PMC8117739 DOI: 10.3748/wjg.v27.i18.2090] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/27/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatitis E virus (HEV) is an important cause of repeated waterborne outbreaks of acute hepatitis. Recently, several extrahepatic manifestations (EHMs) have been described in patients with HEV infection. Of these, neurological disorders are the most common EHM associated with HEV. The involvement of both the peripheral nervous system and central nervous system can occur together or in isolation. Patients can present with normal liver function tests, which can often be misleading for physicians. There is a paucity of data on HEV-related neurological manifestations; and these data are mostly described as case reports and case series. In this review, we analyzed data of 163 reported cases of HEV-related neurological disorders. The mechanisms of pathogenesis, clinico-demographic profile, and outcomes of the HEV-related neurological disorders are described in this article. Nerve root and plexus disorder were found to be the most commonly reported disease, followed by meningoencephalitis.
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Affiliation(s)
- Ashish Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna 800014, India
| | - Gaurav Kumar
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna 800014, India
| | - Vishwa Mohan Dayal
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna 800014, India
| | - Abhay Ranjan
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna 800014, India
| | - Arya Suchismita
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, Basant Kunj 110070, New Delhi, India
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Mendoza-Lopez C, Lopez-Lopez P, Atienza-Ayala S, Rivero-Juarez A, Benito R. Parsonage-Turner syndrome associated with hepatitis E infection in immunocompetent patients. Virus Res 2020; 290:198165. [PMID: 33007343 DOI: 10.1016/j.virusres.2020.198165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 02/08/2023]
Abstract
Introduction The hepatitis E virus (HEV) is the leading cause of acute hepatitis around the world. In recent years, knowledge has increased concerning extrahepatic manifestations caused by HEV, including neurological manifestations such as Parsonage-Turner syndrome (PTS). PTS is characterized by severe shoulder or arm pain and patchy paresis with muscle weakness. The aim of the present study was to assess the association between HEV and PTS. Materials and Methods We reported two cases of PTS associated with HEV, which were diagnosed in a short period of time in the same village. PTS was diagnosed by physical examination and electrophysiological studies, and serology testing for IgM, low-avidity IgG, and RNA of HEV established the diagnosis of acute HEV infection. Results A 44-year-old man who presented cervicobrachial pain accompanied by paresthesia, dyspnea, and isolated derangement of liver enzymes and 57-year-old women with cervical pain radiated to upper limbs, paresthesia, and liver cytolysis, although, this patient was initially diagnosed as having drug-induced hepatitis. Finally, the diagnosis was Parsonage- Turner syndrome associated with hepatitis e virus. In both patients, symptoms were bilateral and they required hospital admission. Both consumed vegetables are grown in a local patch and the phylogenetic analysis showed genotype 3f. Then, we reviewed the literature on PTS and HEV and we found 62 previously described cases that were more likely to be men (86.20 %) with more frequent bilateral symptoms (85.71 %). Genotype 3 is the most commonly associated. Three of those cases were diagnosed in Spain. Conclusions According to our findings, HEV should be considered in patients with neuralgic amyotrophy, including those with the absence of liver cytolysis.
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Affiliation(s)
- Claudia Mendoza-Lopez
- Microbiology Department, University Clinical Lozano Blesa Hospital, Zaragoza, Spain.
| | - Pedro Lopez-Lopez
- Infectious Diseases Unit, Clinical Virology and Zoonoses Unit, Maimonides Institute for Biomedical Research, Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Saida Atienza-Ayala
- Neurology Department, University Clinical Lozano Blesa Hospital, Zaragoza, Spain
| | - Antonio Rivero-Juarez
- Infectious Diseases Unit, Clinical Virology and Zoonoses Unit, Maimonides Institute for Biomedical Research, Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Rafael Benito
- Microbiology Department, University Clinical Lozano Blesa Hospital, Zaragoza, Spain
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Velay A, Kack-Kack W, Abravanel F, Lhomme S, Leyendecker P, Kremer L, Chamouard P, Izopet J, Fafi-Kremer S, Barth H. Parsonage-Turner syndrome due to autochthonous acute genotype 3f hepatitis E virus infection in a nonimmunocompromised 55-year-old patient. J Neurovirol 2017; 23:615-620. [PMID: 28439773 DOI: 10.1007/s13365-017-0525-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/06/2017] [Accepted: 03/13/2017] [Indexed: 01/05/2023]
Abstract
Hepatitis E virus (HEV) infection is an emerging autochthonous disease in industrialized countries. Extra-hepatic manifestations, in particular neurologic manifestations, have been reported in HEV infection. Only a few cases of hepatitis E-associated Parsonage-Turner syndrome have been reported, and HEV genotypes were rarely determined. Here, we report the case of a Parsonage-Turner syndrome associated with an acute autochthonous HEV infection in a 55-year-old immunocompetent patient. HEV genomic RNA was detected in serum and cerebrospinal fluid samples (CSF), and molecular phylogenetic analysis of HEV was performed. The interest of this case lies in its detailed description notably the molecular analysis of HEV RNA isolated from serum and CSF. HEV infection should be considered in diagnostic investigations of neurologic manifestations associated with liver function perturbations.
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Affiliation(s)
- A Velay
- Virology Laboratory, University Hospital of Strasbourg, F-67000, Strasbourg, France. .,INSERM, IRM UMR-S 1109, F-67000, Strasbourg, France.
| | - W Kack-Kack
- Virology Laboratory, University Hospital of Strasbourg, F-67000, Strasbourg, France.,INSERM, IRM UMR-S 1109, F-67000, Strasbourg, France
| | - F Abravanel
- INSERM, U1043, Centre de Physiopathologie de Toulouse Purpan, F-31300, Toulouse, France.,CHU Toulouse Hôpital Purpan, Laboratoire de virologie, Institut fédératif de biologie de Purpan, F-31300, Toulouse, France
| | - S Lhomme
- INSERM, U1043, Centre de Physiopathologie de Toulouse Purpan, F-31300, Toulouse, France.,CHU Toulouse Hôpital Purpan, Laboratoire de virologie, Institut fédératif de biologie de Purpan, F-31300, Toulouse, France
| | - P Leyendecker
- Department of Neuroradiology, University Hospital of Strasbourg, F-67098, Strasbourg, France
| | - L Kremer
- Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, UMR_S INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - P Chamouard
- Department of Gastroenterology and Hepatology, University Hospital of Strasbourg, F-67098, Strasbourg, France
| | - J Izopet
- INSERM, U1043, Centre de Physiopathologie de Toulouse Purpan, F-31300, Toulouse, France.,CHU Toulouse Hôpital Purpan, Laboratoire de virologie, Institut fédératif de biologie de Purpan, F-31300, Toulouse, France
| | - S Fafi-Kremer
- Virology Laboratory, University Hospital of Strasbourg, F-67000, Strasbourg, France.,INSERM, IRM UMR-S 1109, F-67000, Strasbourg, France
| | - H Barth
- Virology Laboratory, University Hospital of Strasbourg, F-67000, Strasbourg, France.,INSERM, IRM UMR-S 1109, F-67000, Strasbourg, France
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Neuralgic amyotrophy triggered by hepatitis E virus: a particular phenotype. J Neurol 2017; 264:770-780. [PMID: 28247042 DOI: 10.1007/s00415-017-8433-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/19/2017] [Accepted: 02/20/2017] [Indexed: 01/12/2023]
Abstract
The neuralgic amyotrophy may be of difficult diagnosis, due to phenotypic variability, with different initial presentations (upper plexus multiple mononeuropathy, lumbosacral involvement, distal reached, phrenic involvement). To date, there is little guidance on these patients' therapeutic management, especially those for which neuralgic amyotrophy is triggered by hepatitis E virus (HEV-NA). The study aims to identify specific features that characterize patients bearing the neuralgic amyotrophy triggered by HEV. We first describe a new case report of HEV-neuralgic amyotrophy, with delayed diaphragmatic reach. Then, the literature was searched for reports of HEV-NA (n = 39), and neuralgic amyotrophy with phrenic paresis (n = 42) from 1999 to June 2016. Relevant data were retrieved, analyzed and compared with the parameters of idiopathic neuralgic amyotrophy (n = 199) of the largest cohort, described by Van Alfen and Van Engelen in 2006. Compared to the published cohort, HEV-NA patients were more likely to be men (M/F 34/5 vs. 136/63, p = 0.017), with more frequent bilateral symptoms (86.8% cases vs. 28.5%, p < 0.0001) as well as phrenic paresis (18.0 vs. 6.6%, p = 0.028). The clinical improvement is poor, with 15.6% of cases with remission only. A particular phenotype characteristic of the HEV-induced neuralgic amyotrophy has arisen. Our findings call for action in validating the above-mentioned features that illustrate the HEV-NA cases as an early diagnosis would prevent complications, especially the phrenic damage often associated with a worse functional outcome.
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Silva M, Wicki B, Tsouni P, Cunningham S, Doerig C, Zanetti G, Aubert V, Sahli R, Moradpour D, Kuntzer T. Hepatitis E virus infection as a direct cause of neuralgic amyotrophy. Muscle Nerve 2016; 54:325-7. [PMID: 26939568 DOI: 10.1002/mus.25096] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION We describe a patient who developed neuralgic amyotrophy (NA) related to hepatitis E virus (HEV) infection. METHODS The patient underwent neurological and electrodiagnostic examinations, high-resolution analysis of serological changes, and HEV load profile, and was treated with intravenous immunoglobulin. RESULTS There was evidence of bilateral, asymmetric acute inflammatory cervical polyradiculopathy and possible brachial plexopathy. Positive serum anti-HEV IgM was followed by seroconversion to anti-HEV IgG positivity. A calculated anti-HEV antibody index was compatible with intrathecal synthesis, and HEV genotype 3 RNA was found in serum and cerebrospinal fluid (CSF). Liver function tests returned to normal within 6 weeks. CONCLUSIONS Bilateral involvement of cervical nerve roots and/or plexus, elevated liver function tests, and abnormal CSF are typical features of HEV-associated NA. The pathogenesis involves possible immune-mediated mechanisms. However, our findings support the hypothesis that HEV-related NA is associated with direct infection. Muscle Nerve 54: 325-327, 2016.
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Affiliation(s)
- Mauro Silva
- Service of Neurology, Department of Clinical Neurosciences, University Hospital Lausanne (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Benoît Wicki
- Service of Neurology, Department of Clinical Neurosciences, University Hospital Lausanne (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Pinelopi Tsouni
- Service of Neurology, Department of Clinical Neurosciences, University Hospital Lausanne (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Sophie Cunningham
- Service of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Christopher Doerig
- Service of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Giorgio Zanetti
- Service of Infectious Diseases, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.,Service of Hospital Preventive Medicine, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Vincent Aubert
- Service of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Roland Sahli
- Institute of Microbiology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Darius Moradpour
- Service of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Thierry Kuntzer
- Service of Neurology, Department of Clinical Neurosciences, University Hospital Lausanne (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
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7
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Dalton HR, Kamar N, van Eijk JJJ, Mclean BN, Cintas P, Bendall RP, Jacobs BC. Hepatitis E virus and neurological injury. Nat Rev Neurol 2015; 12:77-85. [PMID: 26711839 DOI: 10.1038/nrneurol.2015.234] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis E is hyperendemic in many developing countries in Asia and Africa, and is caused by hepatitis E virus (HEV) genotypes 1 and 2, which are spread via the faecal-oral route by contaminated water. Recent data show that HEV infection is also endemic in developed countries. In such geographical settings, hepatitis E is caused by HEV genotypes 3 and 4, and is mainly a porcine zoonosis. In a minority of cases, HEV causes acute and chronic hepatitis, but infection is commonly asymptomatic or unrecognized. HEV infection is associated with a number of extrahepatic manifestations, including a range of neurological injuries. To date, 91 cases of HEV-associated neurological injury--most commonly, Guillain-Barré syndrome, neuralgic amyotrophy, and encephalitis/myelitis--have been reported. Here, we review the reported cases, discuss possible pathogenic mechanisms, and present our perspectives on future directions and research questions.
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Affiliation(s)
- Harry R Dalton
- Royal Cornwall Hospital, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK.,European Centre for Environment &Human Health, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK
| | - Nassim Kamar
- Departments of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, 1 Avenue J. Poulhès, Toulouse Cedex 9, France
| | - Jeroen J J van Eijk
- Department of Neurology, Jeroen Bosch Ziekenhuis (JBZ), Henri Dunantstraat 1, 5223 GZ, 's-Hertogenbosch, Netherlands
| | - Brendan N Mclean
- Royal Cornwall Hospital, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK
| | - Pascal Cintas
- Department of Neurology, Pierre Paul Riquet Hospital, CHU Purpan, Place du Dr Baylac, 31059 Toulouse, France
| | - Richard P Bendall
- Royal Cornwall Hospital, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK.,European Centre for Environment &Human Health, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK
| | - Bart C Jacobs
- Department of Neurology/Neuro-Immunology Erasmus MC, Erasmus MC, Afdeling Neurologie, Kamer EE 2287, Postbus 2040, 3000 CA Rotterdam, Netherlands
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Bazerbachi F, Haffar S, Garg SK, Lake JR. Extra-hepatic manifestations associated with hepatitis E virus infection: a comprehensive review of the literature. Gastroenterol Rep (Oxf) 2015; 4:1-15. [PMID: 26358655 PMCID: PMC4760069 DOI: 10.1093/gastro/gov042] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 07/09/2015] [Indexed: 02/07/2023] Open
Abstract
Background and aims: Hepatitis E virus (HEV) infection is a significant public health problem that afflicts almost 20 million individuals annually and causes acute liver injury in 3.5 million, with approximately 56 000 deaths. As with other viral hepatitides, extra-hepatic manifestations could represent an important aspect of this infection. The spectrum of these manifestations is still emerging. Acute pancreatitis and neurological, musculoskeletal, hematological, renal, and other immune-mediated manifestations have been described. The aim of this article is to comprehensively review the published literature of extra-hepatic manifestations associated with HEV infection. Data sources: We searched the PubMed database using the MeSH term “hepatitis E” and each of the extra-hepatic manifestations associated with HEV infection. No language or date restrictions were set in these searches. Searches retrieving articles with non-A, non-B hepatitis were excluded. Additional articles were identified through the reference lists of included articles. Results: Several extra-hepatic manifestations associated with HEV infection have been published. The temporal association between some extra-hepatic manifestations and HEV infection and the exclusion of other possible etiologies suggests that HEV infection could have caused some of them. According to the available data, HEV infection appears to be strongly associated with acute pancreatitis, neurological disorders (with primarily dominant peripheral nerve involvement, most commonly manifested as Guillain-Barré syndrome, followed by neuralgic amyotrophy), hematological diseases (hemolytic anemia due to glucose phosphate dehydrogenase deficiency, and severe thrombocytopenia), glomerulonephritis, and mixed cryoglobulinemia. More data are needed to clarify whether an association exists with musculoskeletal or other immune-mediated manifestations. Conclusions: HEV infection should be considered in patients with acute pancreatitis, Guillain-Barré syndrome, neuralgic amyotrophy, hemolytic anemia due to glucose phosphate dehydrogenase deficiency, severe thrombocytopenia, glomerulonephritis, and mixed cryoglobulinemia. Alternatively, signs and symptoms of these conditions should be sought in patients with acute or chronic HEV infection. More data are needed to confirm the role of HEV in other extra-hepatic disorders.
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Affiliation(s)
- Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Samir Haffar
- Department of Gastroenterology and Hepatology, University of Damascus, Damascus, Syrian Arab Republic
| | - Sushil K Garg
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
| | - John R Lake
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
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