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Santos-Silva S, da Silva Dias Moraes DF, López-López P, Rivero-Juarez A, Mesquita JR, Nascimento MSJ. Hepatitis E Virus in the Iberian Peninsula: A Systematic Review. FOOD AND ENVIRONMENTAL VIROLOGY 2023; 15:193-211. [PMID: 37434079 PMCID: PMC10499749 DOI: 10.1007/s12560-023-09560-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023]
Abstract
One of the most frequent causes of acute viral hepatitis is hepatitis E virus (HEV) causing 20 million infections worldwide each year and 44,000 deaths. Studies on HEV in the Iberian Peninsula have been increasing through time with HEV infection being identified in humans and animals. The aim of the present systematic review was to compile and evaluate all the published data on HEV from studies performed in humans, animals and environmental samples in the Iberian Peninsula. The electronic databases Mendeley, PubMed, Scopus, and Web of Science were thoroughly searched, and research published up until February 01, 2023 were included. Resulting in a total of 151 eligible papers by full reading and application of PRISMA exclusion/inclusion criteria. Overall, the present review shows that several HEV genotypes, namely HEV-1, 3, 4, and 6 as well as Rocahepevirus, are circulating in humans, animals, and in the environment in the Iberian Peninsula. HEV-3 was the most common genotype circulating in humans in Portugal and Spain, as expected for developed countries, with HEV-1 only being detected in travelers and emigrants from HEV endemic regions. Spain is the biggest pork producer in Europe and given the high circulation of HEV in pigs, with HEV-3 being primarily associated to zoonotic transmission through consumption of swine meat and meat products, in our opinion, the introduction of an HEV surveillance system in swine and inclusion of HEV in diagnostic routines for acute and chronic human hepatitis would be important. Additionally, we propose that establishing a monitoring mechanism for HEV is crucial in order to gain a comprehensive understanding of the prevalence of this illness and the various strains present in the Iberian Peninsula, as well as their potential impact on public health.
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Affiliation(s)
- Sérgio Santos-Silva
- ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | | | - Pedro López-López
- Grupo de Virología Clínica y Zoonosis, Unidad de Enfermedades Infecciosas, Instituto Maimónides de Investigación Biomédica de Córdoba, Hospital Reina Sofía, Universidad de Córdoba, Córdoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - António Rivero-Juarez
- Grupo de Virología Clínica y Zoonosis, Unidad de Enfermedades Infecciosas, Instituto Maimónides de Investigación Biomédica de Córdoba, Hospital Reina Sofía, Universidad de Córdoba, Córdoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - João R Mesquita
- ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.
- Epidemiology Research Unit (EPIUnit), Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal.
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal.
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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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Rawla P, Raj JP, Kannemkuzhiyil AJ, Aluru JS, Thandra KC, Gajendran M. A Systematic Review of the Extra-Hepatic Manifestations of Hepatitis E Virus Infection. Med Sci (Basel) 2020; 8:E9. [PMID: 32033102 PMCID: PMC7151617 DOI: 10.3390/medsci8010009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 02/06/2023] Open
Abstract
Hepatitis E virus (HEV) is a non-enveloped, positive-sense, single-stranded RNA icosahedral virus belongs to the genus Orthohepevirus within the Hepeviridae family. HEV infection can be asymptomatic, or it can cause icteric or fulminant hepatitis. Off late, there have been a number of publications reporting the extra-hepatic manifestations of HEV infection, and this systematic review is aimed at summarizing the available evidence in this regard. Two independent investigators searched PubMed, PubMed Central and Embase databases using the search string "(((hepatitis E) AND (Extrahepatic OR Extra-Hepatic))) OR ((Hepatitis E) AND (Neurology OR Cardiology OR Respiratory OR Lung OR Gastrointestinal OR musculoskeletal OR immunology OR pulmonary)) Filters: Abstract availability, English language, and Human studies". The extra-hepatic manifestations reported in each of the selected articles were classified and reported as neurological, cardiovascular, and hematological and miscellaneous manifestations. The total number of various manifestations reported in our study were n = 324. These include neurological manifestations (n = 178/324 (54.94%)), cardiovascular and hematological manifestations (n = 113/324 (34.88%)), gastro-intestinal/pancreaticobiliary manifestations (n = 24/324 (7.41%)) and other rarer manifestations involving systems such as renal (n = 4/324; 1.24%), endocrine (n = 1/324; 0.31%), dermatology (n = 1/324; 0.31%), respiratory (n = 1/324; 0.31%), muscular (n = 1/324; 0.31%) and immune system (n = 1/324; 0.31%). Thus, HEV can have extra-hepatic manifestations affecting any system of the human body. Further research is needed to elucidate the underlying pathophysiological manifestations of these extra-hepatic manifestations and to prove causal association with HEV.
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Affiliation(s)
- Prashanth Rawla
- Department of Medicine, Sovah Health, Martinsville, VA 24112, USA
| | - Jeffrey Pradeep Raj
- Department of Clinical Pharmacology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai 400012, India;
| | - Alan Jose Kannemkuzhiyil
- St. Johns Medical College, St. John’s National Academy of Health Sciences, Bengaluru, Karnataka 560034, India;
| | - John Sukumar Aluru
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02212, USA;
| | - Krishna Chaitanya Thandra
- Department of Pulmonary and Critical Care Medicine, Sentara Virginia Beach General Hospital, Virginia Beach, VA 23454, USA;
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA;
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Liu H, Ma Y. Hepatitis E virus-associated Guillain-Barre syndrome: Revision of the literature. Brain Behav 2020; 10:e01496. [PMID: 31828968 PMCID: PMC6955827 DOI: 10.1002/brb3.1496] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/12/2019] [Accepted: 11/16/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The association between preceding infection of hepatitis E virus (HEV) and Guillain-Barre syndrome (GBS) has been found for more than a decade, while hepatitis E virus-associated Guillain-Barre syndrome (HEV-associated GBS) still remains poorly understood. Initially discovered in 2000, the association between GBS and HEV has been focused by neurologists increasingly. Five percent of patients with GBS had preceding acute HEV infection in the Netherlands and higher rate was found in Bangladesh (11%) where HEV is endemic. METHOD An extensive review of relevant literature was undertaken. RESULTS Hepatitis E virus infection may induce GBS via direct viral damage according to recent research findings. On the other hand, the presence of antiganglioside GM1 or GM2 antibodies in serum of some HEV-associated GBS patients indicates that HEV infection may trigger GBS by activating autoimmune response to destroy myelin or axon mistakenly. Management of HEV-associated GBS has no obvious difference from GBS. It mainly consists of supportive therapy and immunotherapy. Intravenous immunoglobulin (IVIG) or plasma exchange (PLEX) was used in most reported cases, which is the main strategy for clinical treatment of HEV-associated GBS. Whether antiviral therapy could be additional strategy other than the routine therapy to shorten the length of disease course is one of the most urgent problems and requires further study. CONCLUSIONS An overview of possible pathogenesis will gain a first insight into why HEV, traditionally recognized as only hepatotropic, can induce many neurological disorders represented by GBS. Moreover, understanding of the underlying mechanisms may contribute to development of a novel therapeutic strategy. This review also summarizes management and clinical characteristics of HEV-associated GBS, aiming to achieve early recognition and good recovery.
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Affiliation(s)
- Hang Liu
- Department of NeurologyShengjing HospitalChina Medical UniversityShenyangChina
| | - Ying Ma
- Department of NeurologyShengjing HospitalChina Medical UniversityShenyangChina
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Choudhary MC, Bajpai V, Anand L, Gupta E. Guillain-Barré syndrome in a patient of acute Hepatitis E virus infection associated with genotype 1: Case report and literature review. Intractable Rare Dis Res 2019; 8:43-47. [PMID: 30881857 PMCID: PMC6409121 DOI: 10.5582/irdr.2018.01099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hepatitis E is a serious public health problem in developing countries. Most of the patients with Hepatitis E virus (HEV) infection present with typical acute hepatitis symptoms. However, in few patients it may lead to complications such as liver failure and extrahepatic symptoms. One of the rare extrahepatic presentations of this infection is neurological complications such as Guillain-Barré syndrome (GBS) which is observed in 5.5% of HEV infected patients (mainly in developed countries). Moreover, only genotype (gt) 3 HEV was found in association with GBS among patients in developed countries whereas molecular characterisation of HEV cases detected from developing countries have not been reported till now. Here, we are reporting a case of GBS as an extrahepatic complication of HEV associated with gt1 identified by molecular characterization by performing PCR of open-reading frame 2 (ORF2) region of HEV. Phylogenetic analysis by maximum likelihood method revealed that HEV gt1 case reported in this paper rooted closely with other HEV gt1 samples from South-Asian countries with high bootstrap values indicative of fully resolved tree.
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Affiliation(s)
- Manish Chandra Choudhary
- Department of Virology, Institute of Liver and Biliary Sciences, New Delhi, India
- Molecular and Cellular Medicine department, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vijeta Bajpai
- Department of Virology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Lovkesh Anand
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ekta Gupta
- Department of Virology, Institute of Liver and Biliary Sciences, New Delhi, India
- Address correspondence to:Dr. Ekta Gupta, Department of Virology, Institute of Liver and Biliary Sciences, New Delhi 110070, India. E-mail:
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Mesquita JR, Almeida-Santos M, Fernandes M, Maltez F, Lino S, Alves L, Abreu-Silva J, Oliveira RMS, Curran MD, Nascimento MSJ. Hepatitis E Virus Genotype 1 Cases Imported to Portugal from India, 2016. Ann Hepatol 2018; 17:335-338. [PMID: 29469037 DOI: 10.5604/01.3001.0010.8667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hepatitis E in industrialized countries is mainly associated with genotype 3 hepatitis E virus (HEV) and normally causes a sporadic self-limiting disease in immunocompetent individuals. Unlike genotype 3, genotypes 1 and 2 circulate in developing countries, produce severe disease and occur in the epidemic form. Hepatitis E occurring in travellers returning from endemic areas in developing countries is not a novel epidemiological occurrence, however the vast majority of cases remain to be genetically studied. The present study describes two cases of severe acute hepatitis E that required hospitalization for 6 and 9 days in two individuals of Indian nationality that had recently migrated to Portugal to work. The retrieved HEV sequences both belonged to genotype 1 and had a high degree of nucleotide sequence identity, clustering with strains isolated in India and Nepal, in 2013 and 2014. Confirmed HEV genotypes of increased pathogenicity like genotype 1 are being introduced into otherwise naïve populations of industrialized countries such as European countries with consequences difficult to predict. As far as we know the present study is the first in Portugal to describe and genetically characterize imported cases of hepatitis E infection caused by HEV genotype 1.
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Affiliation(s)
- João R Mesquita
- Epidemiology ReserchUnit (EPIUnit), Institute of Public Health, University of Porto, 4050-313 Porto, Portugal. Instituto Politécnico de Viseu, Viseu, Portugal
| | - Madalena Almeida-Santos
- Laboratório de Patologia Clínica Centro Hospitalar Lisboa Central (CHLC) - Hospital Curry Cabral, 1069-166 Lisboa, Portugal
| | - Maria Fernandes
- Laboratório de Patologia Clínica Centro Hospitalar Lisboa Central (CHLC) - Hospital Curry Cabral, 1069-166 Lisboa, Portugal
| | - Fernando Maltez
- Serviço de Doenças Infeciosas CHLC - Hospital Curry Cabral, 1069-166 Lisboa, Portugal
| | - Sara Lino
- Laboratório de Patologia Clínica Centro Hospitalar Lisboa Central (CHLC) - Hospital Curry Cabral, 1069-166 Lisboa, Portugal
| | - Liliana Alves
- Laboratório de Patologia Clínica Centro Hospitalar Lisboa Central (CHLC) - Hospital Curry Cabral, 1069-166 Lisboa, Portugal
| | - Joana Abreu-Silva
- Universidade do Porto, 4050-313 Porto, Portugal. Laboratório de Microbiologia, Departamento de Ciências Biológicas, Faculdade de Farmácia
| | - Ricardo M S Oliveira
- Universidade do Porto, 4050-313 Porto, Portugal. Laboratório de Microbiologia, Departamento de Ciências Biológicas, Faculdade de Farmácia
| | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Public Health England, Addenbrooke´s Hospital, Cambridge, UK
| | - Maria S J Nascimento
- Universidade do Porto, 4050-313 Porto, Portugal. Laboratório de Microbiologia, Departamento de Ciências Biológicas, Faculdade de Farmácia
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7
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Zheng X, Yu L, Xu Q, Gu S, Tang L. Guillain-Barre syndrome caused by hepatitis E infection: case report and literature review. BMC Infect Dis 2018; 18:50. [PMID: 29357816 PMCID: PMC5778630 DOI: 10.1186/s12879-018-2959-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Hepatitis E infection is a global disorder that causes substantial morbidity. Numerous neurologic illnesses, including Guillain–Barre syndrome (GBS), have occurred in patients with hepatitis E virus (HEV) infection. Case presentation We report a 58 year-old non-immunocompromised man who presented with progressive muscle weakness in all extremities during an episode of acute HEV infection, which was confirmed by measuring the anti-HEV IgM antibodies in the serum. Both cerebrospinal fluid examination and electrophysiological study were in agreement with the diagnosis of HEV-associated GBS. Following the treatment with intravenous immunoglobulin, the patient’s neurological condition improved rapidly. Conclusions HEV infection should be strongly considered in patients with neurological symptoms, especially those with elevated levels of liver enzymes. Electronic supplementary material The online version of this article (10.1186/s12879-018-2959-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiaoqin Zheng
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Liang Yu
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Qiaomai Xu
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Silan Gu
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Lingling Tang
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China.
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Nascimento MSJ, Pereira SS, Teixeira J, Abreu-Silva J, Oliveira RMS, Myrmel M, Stene-Johansen K, Øverbø J, Gonçalves G, Mesquita JR. A nationwide serosurvey of hepatitis E virus antibodies in the general population of Portugal. Eur J Public Health 2017; 28:720-724. [DOI: 10.1093/eurpub/ckx213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Maria S J Nascimento
- Department of Biological Sciences, Faculty of Pharmacy of the University of Porto (FFUP), Porto, Portugal
| | - Sara S Pereira
- Department of Biological Sciences, Faculty of Pharmacy of the University of Porto (FFUP), Porto, Portugal
| | - Joana Teixeira
- Department of Biological Sciences, Faculty of Pharmacy of the University of Porto (FFUP), Porto, Portugal
| | - Joana Abreu-Silva
- Department of Biological Sciences, Faculty of Pharmacy of the University of Porto (FFUP), Porto, Portugal
| | - Ricardo M S Oliveira
- Department of Biological Sciences, Faculty of Pharmacy of the University of Porto (FFUP), Porto, Portugal
| | - Mette Myrmel
- Department of Food Safety and Infection Biology, Norwegian University of Life Sciences, Oslo, Norway
| | | | - Joakim Øverbø
- Department of Vaccine Preventable Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Guilherme Gonçalves
- Unit for Multidisciplinary Research in Biomedicine (UMIB), Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - João R Mesquita
- Agrarian Superior School (ESAV), Centre for Studies in Education, Technologies and Health (CI&DETS), Polytechnic Institute of Viseu, Viseu, Portugal
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Pischke S, Hartl J, Pas SD, Lohse AW, Jacobs BC, Van der Eijk AA. Hepatitis E virus: Infection beyond the liver? J Hepatol 2017; 66:1082-1095. [PMID: 27913223 DOI: 10.1016/j.jhep.2016.11.016] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/13/2016] [Accepted: 11/20/2016] [Indexed: 02/07/2023]
Abstract
Hepatitis E virus (HEV) infections are not limited to the liver but may also affect other organs. Several diseases, including Guillain-Barré syndrome, neuralgic amyotrophy, glomerulonephritis, cryoglobulinemia, pancreatitis, lymphoma, thrombopenia, meningitis, thyroiditis and myocarditis have been observed in the context of hepatitis E. To date, the definite pathophysiological links between HEV and extrahepatic manifestations are not yet established. However, it is suggested that HEV infection might be causative based on serological studies, case series, in vitro data and animal models. In particular, neuronal and renal diseases as well as pancreatitis seem to be caused by HEV, while a causative relationship between HEV and other diseases is more doubtful. Either direct cytopathic tissue damage by extrahepatic replication, or immunological processes induced by an overwhelming host immune response, are possible origins of HEV-associated extrahepatic manifestations. Hepatologists should be aware of the possibility that acute or chronically HEV-infected patients could develop extrahepatic manifestations. Neurologists, nephrologists, rheumatologists and other groups of physicians should consider HEV infection as a potential differential diagnosis when observing one of the diseases described in this review. Ribavirin and steroids have been used in small groups of patients with extrahepatic manifestations of HEV, but the efficacy of these drugs still needs to be verified by large, multicenter studies. This article comprehensively reviews the published literature regarding HEV and extrahepatic manifestations. We discuss the probability of specific extrahepatic diseases being caused by previous or ongoing HEV infection, and summarize the published knowledge about antiviral treatment in extrahepatic disorders.
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Affiliation(s)
- Sven Pischke
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - Johannes Hartl
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Suzan D Pas
- Department of Viroscience, Erasmus MC University Medical Center Rotterdam, Netherlands
| | - Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC University Medical Center Rotterdam, Netherlands
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Saint-Jacques P, Tissot-Dupont H, Colson P. Autochthonous infection with hepatitis E virus related to subtype 3a, France: a case report. Ann Hepatol 2017; 15:438-41. [PMID: 27049499 DOI: 10.5604/16652681.1198823] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hepatitis E virus (HEV) recently emerged in Europe as a cause of autochthonous acute hepatitis and a porcine zoonosis. European autochthonous cases almost exclusively involved viruses of genotype 3, subtype 3a being only recently reported in France, from farm pigs. We report an autochthonous human infection with a HEV related to subtype 3a in Southeastern France. A 55-year-old human immunodeficiency virus-infected man presented liver cytolysis in June 2014. HEV RNA was detected in serum and three months later, anti-HEV IgM and IgG were positive whereas HEV RNA was no more detectable in serum. No biological or clinical complication did occur. HEV phylogeny based on two capsid gene fragments showed clustering of sequences obtained from the case-patient with HEV-3a, mean nucleotide identity being 91.7 and 91.3% with their 10 best GenBank matches that were obtained in Japan, South Korea, USA, Canada, Germany and Hungria from humans, pigs and a mongoose. Identity between HEV sequence obtained here and HEV-3a sequences obtained at our laboratory from farm pigs sampled in 2012 in Southeastern France was only 90.2-91.4%. Apart from these pig sequences, best hits from France were of subtypes 3i, 3f, or undefined. The patient consumed barely cooked wild-boar meat; no other risk factor for HEV infection was documented. In Europe, HEV-3a has been described in humans in England and Portugal, in wild boars in Germany, and in pigs in Germany, the Netherlands, and, recently, France. These findings suggest to gain a better knowledge of HEV-3a circulation in France.
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Affiliation(s)
- Pauline Saint-Jacques
- Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalo-Universitaire Timone, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fédération de Bactériologie-Hygiène-Virologie, Marseille, France
| | - Hervé Tissot-Dupont
- Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalo-Universitaire Timone, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fédération de Bactériologie-Hygiène-Virologie, Marseille, France; Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalo-Universitaire Conception, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Service de Maladies Infectieuses, Marseille, France
| | - Philippe Colson
- Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalo-Universitaire Timone, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fédération de Bactériologie-Hygiène-Virologie, Marseille, France; Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalo-Universitaire Conception, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Service de Maladies Infectieuses, Marseille, France
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11
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Hepatitis E virus genotype 3 in mussels (Mytilus galloprovinciallis), Spain. Food Microbiol 2016; 58:13-5. [DOI: 10.1016/j.fm.2016.03.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 11/18/2022]
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12
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Li Z, Shen J, Liang J, Feng F. Successful surgical treatment of scoliosis secondary to Guillain-Barré syndrome: Case report. Medicine (Baltimore) 2016; 95:e3775. [PMID: 27367981 PMCID: PMC4937895 DOI: 10.1097/md.0000000000003775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute autoimmune inflammatory demyelinating polyneuropathy that mostly affects the peripheral nervous system. Little is reported about spinal deformity associated with GBS. This study aims to present a case of scoliosis occurring in the setting of GBS.Case report and literature review.The patient was a 14-year-old male with scoliosis. His spinal plain radiographs showed that the Cobb angle of thoracic scoliosis was 114°. History review revealed that he developed profound lower extremity pain, weakness, and numbness after catching a cold 5 years ago. These symptoms progressed to unsteady gait and inability to stand up from squatting position. The diagnosis of GBS was confirmed based on these symptoms. He underwent a posterior correction at Thoracic 5-Lumbar 5 (T5-L12) levels using the (LEGACY, USA) spinal system. The Cobb angle was corrected from 114° to 45° (correction rate 60.5%). His follow-up was symptomatic, well balanced in the coronal planes, with solid fusion 12 months after the operation.Neuromuscular scoliosis could develop secondary to GBS. When evaluating patients with acute inflammatory polyneuropathy, clinical examination of the spine is essential to identify patients with rare neuromuscular scoliosis.
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Affiliation(s)
| | - Jianxiong Shen
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Correspondence: Jianxiong Shen, Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking, Union Medical College, Beijing, China (e-mail: )
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13
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Yazaki Y, Sugawara K, Honda M, Ohnishi H, Nagashima S, Takahashi M, Okamoto H. Characteristics of 20 Patients with Autochthonous Acute Hepatitis E in Hokkaido, Japan: First Report of Bilateral Facial Palsy Following the Infection with Genotype 4 Hepatitis E Virus. TOHOKU J EXP MED 2016; 236:263-71. [PMID: 26228039 DOI: 10.1620/tjem.236.263] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Autochthonous hepatitis E is increasingly being recognized in industrialized countries, including Japan. Although neurological abnormalities have been sporadically reported as an extrahepatic manifestation of hepatitis E virus (HEV) infection, it is rare and has not been reported in Japan. The present study aimed to characterize a total of 20 patients consecutively diagnosed with sporadic acute hepatitis E at a city hospital in Hokkaido, Japan, during 2001-2014, focusing on a patient complicated with neuropathy. Seventeen patients were infected with genotype 4 HEV, while the remaining three patients were with genotype 3 HEV. Although a 67-year-old male with severe hepatitis did not have predisposing factors associated with the development of neurological disorders, such as diabetes mellitus and the use of immunosuppressive agents, he developed bilateral peripheral facial palsy six days after admission. A neurological examination revealed the inability to smile, frown, close his eyes completely or puff out his cheeks. MRI brain scans were considered to be normal. Although it took 83 days after admission for the total bilirubin levels to normalize, his neurological symptoms resolved gradually within three weeks without any sequelae following conservative therapy. A full-length genomic analysis of the HEV strain (HE-JA30) isolated from the patient belonged to genotype 4 and was closest to that currently circulating in Hokkaido, Japan. This is the first report of HEV-associated neuropathy in Japan. While all of previous reports on HEV-related neuropathy involve genotype 3 HEV, the present report is unique in that genotype 4 HEV is responsible for the neuropathy.
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14
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Mesquita JR, Myrmel M, Stene-Johansen K, Øverbø J, Nascimento MSJ. A Public Health initiative on hepatitis E virus epidemiology, safety and control in Portugal--study protocol. BMC Infect Dis 2016; 16:17. [PMID: 26774897 PMCID: PMC4715291 DOI: 10.1186/s12879-016-1341-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/07/2016] [Indexed: 01/14/2023] Open
Abstract
Background The discovery of autochthonous hepatitis E in industrialized countries has changed the understanding of hepatitis E virus (HEV) infection in these regions, now known to be mainly due to zoonotic transmission of genotype 3. The foodborne route of transmission via consumption of contaminated meat from HEV infected pigs is well documented as well as the direct occupational exposure to animal reservoirs. Accumulating evidence also points to an emerging potential threat to blood safety after the identification of viremic blood donors and the documentation of HEV-contaminated blood or blood products. Moreover, the origin of several iatrogenic cases remains unclear and porcine-derived pharmaceutic products have been suspected as a cause. Severe morbidity following HEV infection in patients receiving immunosuppressive therapy and in those with severe immunodeficiency from other causes has been recently recognized as a serious consequence of this infection in industrialized countries. In Portugal no large-scale HEV seroprevalence study has been undertaken, no professional risk groups have been identified, and the risk of blood donation from HEV silent infected donors is unknown. The present paper describes seroepidemiological and molecular approaches to answer these questions. Methods/design To address these issues a study protocol was designed that will approach: i) the seroprevalence of HEV among the Portuguese general population; ii) HEV infection among butchers and slaughterhouse workers (occupational risk); iii) the silent HEV infection in Portuguese blood donors (HEV transfusion-associated risk); iv) the potential HEV contamination of porcine-derived pharmaceutical products. Commercial enzyme immunoassays and real-time/conventional RT-PCR assays will be used. Discussion This study is the first evaluation of the seroepidemiological status to HEV infection of the Portuguese population, the first to potentially identify professional risk groups, and to evaluate the safety of blood and blood products and porcine-derived pharmaceutics in Portugal. It will generate valuable data applicable for preventive and control measures against HEV infection (e.g., introduction of systematic screening of blood donors, control of blood products or porcine derived pharmaceutical products), thus helping to manage the burden of this viral disease.
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Affiliation(s)
- João R Mesquita
- Escola Superior Agrária de Viseu, Instituto Politécnico de Viseu, Viseu, Portugal.
| | - Mette Myrmel
- Department of Food Safety and Infection Biology, Norwegian University of Life Sciences, Oslo, Norway.
| | | | - Joakim Øverbø
- Department of Virology, Norwegian Institute of Public Health, Oslo, Norway.
| | - Maria S J Nascimento
- Departamento de Ciências Biológicas, Laboratório de Microbiologia, Faculdade de Farmácia da Universidade do Porto, Rua de Jorge Viterbo Ferreira n.° 228, 4050-313, Porto, Portugal.
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15
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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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16
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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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17
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Colson P, Saint-Jacques P, Ferretti A, Davoust B. Hepatitis E Virus of Subtype 3a in a Pig Farm, South-Eastern France. Zoonoses Public Health 2015; 62:593-8. [PMID: 26102074 DOI: 10.1111/zph.12211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Indexed: 12/16/2022]
Abstract
Hepatitis E virus (HEV) has emerged during the past decade as a causative agent of autochthonous hepatitis and is a clinical concern in Western developed countries. It has been increasingly recognized that pigs are a major reservoir of HEV of genotypes 3 and 4 worldwide and pig-derived food items represent a potential source of infections by these viruses in humans. Hepatitis E virus RNA testing was performed here on faeces from rectal swabs sampled in 2012 from 50 3-month-old farm pigs from the same farm located in south-eastern France than in a previous work conducted in 2007. Pig HEV sequences corresponding to genomic fragments of ORF2 and ORF1 genes were obtained after RT-PCR amplification with in-house protocols. Hepatitis E virus genotype was determined by phylogenetic analysis. Prevalence was similar to that determined 5 years earlier (68% versus 62%). Two robust phylogenetic clusters of HEV subtypes 3a and 3f were identified, and these sequences obtained in 2012 largely differ compared with those obtained in 2007. Notably, HEV sequences obtained in 2012 from a majority (62%) of the infected pigs belonged to subtype 3a, which was not previously described in France, including not being found in any of humans, pigs or wild boars. Further studies are needed to assess the circulation of HEV-3a in pigs and humans in this country. In addition, along with previous findings, this study supports the need for increased information to the public on the risk of HEV infection through contacts with pigs or consumption of pig-derived products in France.
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Affiliation(s)
- P Colson
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE) UM 63 CNRS 7278 IRD 198 INSERM U1095, Aix-Marseille Université, Marseille, France.,Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fédération de Bactériologie-Hygiène-Virologie, Centre Hospitalo-Universitaire Timone, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - P Saint-Jacques
- Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fédération de Bactériologie-Hygiène-Virologie, Centre Hospitalo-Universitaire Timone, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - A Ferretti
- Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fédération de Bactériologie-Hygiène-Virologie, Centre Hospitalo-Universitaire Timone, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - B Davoust
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE) UM 63 CNRS 7278 IRD 198 INSERM U1095, Aix-Marseille Université, Marseille, France
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18
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Higuchi MA, Fukae J, Tsugawa J, Ouma S, Takahashi K, Mishiro S, Tsuboi Y. Dysgeusia in a Patient with Guillain-Barré Syndrome Associated with Acute Hepatitis E: A Case Report and Literature Review. Intern Med 2015; 54:1543-6. [PMID: 26073247 DOI: 10.2169/internalmedicine.54.3506] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is usually triggered by viral or bacterial infection. In addition, it was recently reported that infection with hepatitis E virus (HEV) also causes GBS. A 49-year-old man presented with acute-onset paralysis in all extremities and dysgeusia during an episode of acute hepatitis. Serological tests showed the presence of anti-HEV IgM antibodies and HEV-RNA in the serum. As an electrophysiological examination showed acute demyelinating polyradiculoneuropathy, the patient was diagnosed as HEV-associated GBS. Following the initiation of treatment with intravenous immunoglobulin, his paralysis and dysgeusia rapidly improved. This case suggests that HEV-associated GBS may rarely be complicated by dysgeusia.
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19
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Mesquita JR, Oliveira RMS, Coelho C, Vieira-Pinto M, Nascimento MSJ. Hepatitis E Virus in Sylvatic and Captive Wild Boar from Portugal. Transbound Emerg Dis 2014; 63:574-8. [PMID: 25405272 DOI: 10.1111/tbed.12297] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Indexed: 12/26/2022]
Abstract
Hepatitis E virus (HEV) is a zoonotic agent today considered a major Public Health issue in industrialized countries. HEV strains belonging to zoonotic genotype 3 are widely present in swine, being today considered important reservoirs for human disease. Unlike in swine, only scarce data are available on the circulation of HEV in wild boar. This study describes the detection and molecular characterization of HEV in livers from sylvatic wild boar hunted in Portugal and destined for consumption. Additionally, the detection of HEV in stools of a confined wild boar population also destined for consumption is also described. A total of 80 liver samples collected during the hunting season of 2011/2012 and 40 stools collected in February 2012 from a wild boar breeding farm in Portugal were tested by a nested broad-spectrum RT-PCR assay targeting open reading frame (ORF) 1. Twenty livers (25.0%) and 4 stools (10%) were positive for HEV. Phylogenetic analysis showed that all strains clustered with sequences classified as HEV genotype 3 subgenotype e. To our knowledge, this is the first report documenting the occurrence and molecular analysis of HEV in sylvatic and captive wild boar destined for human consumption in Portugal. This report demonstrates for the first time the circulation of HEV in wildlife reservoirs of Portugal adding knowledge to the epidemiology of HEV in wild boar populations.
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Affiliation(s)
- J R Mesquita
- Escola Superior Agrária de Viseu, Instituto Politécnico de Viseu, Viseu, Portugal.,CIBIO/UP, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Vairão, Portugal
| | - R M S Oliveira
- Laboratório de Microbiologia, Faculdade de Farmácia da Universidade do Porto, Porto, Portugal
| | - C Coelho
- Escola Superior Agrária de Viseu, Instituto Politécnico de Viseu, Viseu, Portugal.,CIBIO/UP, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Vairão, Portugal
| | - M Vieira-Pinto
- Centro de Ciência Animal e Veterinária, Universidade de Trás-os-Montes e Alto Douro, Vila Real, Portugal.,Departamento de Ciências Veterinárias, Escola de Ciências Agrárias e Veterinárias Universidade de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - M S J Nascimento
- CIBIO/UP, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Vairão, Portugal.,Laboratório de Microbiologia, Faculdade de Farmácia da Universidade do Porto, Porto, Portugal
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20
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Parvez MK. Hepatitis E virus-associated neuropathy: an emerging extrahepatic manifestation. Future Virol 2014. [DOI: 10.2217/fvl.13.120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Mohammad Khalid Parvez
- Department of Pharmacognosy, King Saud University College of Pharmacy, Riyadh 11451, Saudi Arabia
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