Acute hepatitis E virus infection presenting as a prolonged cholestatic jaundice

Therapeutic Options for the Management of the Cholestatic Phase of Viral Hepatitis A and E-A Systematic Review

Background/Aims

The cholestatic hepatitis associated with acute viral hepatitis leads to prolonged jaundice and pruritus. While several treatment approaches have been proposed, there is a noticeable absence of agreement over the most effective course of action. The goal of this systematic review is to compile and assess the available data on treatment approaches for prolonged hepatitis associated with viral hepatitis.

Methods

We comprehensively searched for relevant studies in MEDLINE, Embase, and Scopus from their inception to May 2024. Studies reporting the treatment option for the management of the cholestatic phase associated with viral hepatitis were included.

Results

A total of 28 studies describing 164 patients were included in the review, of which 18 were case reports, 8 were case series, and 2 were interventional studies. The benefit of ursodeoxycholic acid (UDCA) was reported in two case reports, with doses varying from 10 to 30 mg/kg/d in the included studies. The use of corticosteroids in adult patients was reported in 21 studies, with prednisolone doses varying from 30 to 60 mg/day in adults. Two studies used nasobiliary drain (NBD) for patients who failed to respond to conventional therapy. Lastly, three studies reported using plasma exchange (PLEX) in patients refractory to standard treatment.

Conclusion

Patients not responding to UDCA or cholestyramine may benefit from a short course of corticosteroids, suggesting an immune-mediated phenomenon. NBD placement or PLEX may be tried after analyzing the risk-to-benefit ratio for patients who are nonresponsive to corticosteroids. Further research is required to determine the optimal treatment strategy.

Cholestasis in hepatitis E virus infection

Hepatitis E virus (HEV) infection causes acute hepatitis, chronic hepatitis, particularly in compromised hosts, and various extrahepatic manifestations. HEV infection is reportedly associated with biliary-pancreatic diseases, such as gallstones, cholangitis, choledocholithiasis, and acute pancreatitis. Severe jaundice and prolonged cholestasis are also atypical manifestations of HEV infection. The mechanism and genes involved in cholestasis, namely sinusoidal uptake of blood, bile salt synthesis and secretion from hepatocytes to the canaliculus, have been elucidated. HEV infection triggers severe jaundice and prolonged cholestasis in patients with genetic variants in adenosine triphosphatase phospholipid transporting 8B1, adenosine triphosphate-binding cassette (ABC) protein B4, ABCB11, Myosin VB, and/or farnesoid X receptor (FXR/NR1H4). Although prolonged cholestasis associated with these gene mutations does not seem to be specific to HEV infection, these mutations may be risk factors related to the severity of HEV infection. The use of the pregnane X receptor agonist rifampicin and the peroxisome proliferator-activated receptor activator bezafibrate may be useful for the treatment of cholestasis. These studies provide new insights into understanding the mechanisms of severe jaundice and prolonged cholestasis caused by HEV infection.

Acute Viral Hepatitis E Presenting With Bell's Palsy and Acute Pancreatitis: A Case Report

Hepatitis E is a hepatotropic virus and the most common cause of acute viral hepatitis among adults in India. It has four genotypes, and genotype 1 is mostly associated with sporadic cases. It typically causes self-limiting acute hepatitis following a prodromal course. However, a subset of patients presents with cholestatic features mimicking primary cholestatic liver diseases like primary biliary cholangitis or primary sclerosing cholangitis. Liver injury ranges from asymptomatic rise of liver enzymes to fulminant liver failure. The hepatitis E virus (HEV) has also been implicated in various extrahepatic manifestations such as acute pancreatitis, Guillain-Barré syndrome (GBS), radiculopathy, autoimmune hemolysis, and Bell's palsy. We present an interesting case of acute viral hepatitis E presenting with cholestatic jaundice and extrahepatic manifestations.

Natural History, Clinical Manifestations, and Pathogenesis of Hepatitis E Virus Genotype 1 and 2 Infections

Infection with genotype 1 or 2 hepatitis E virus (HEV) results primarily from human-to-human transmission through the fecal-oral route in low-resource countries. It presents primarily as "acute viral hepatitis" syndrome, usually a self-limiting illness. A few cases progress to acute liver failure, a serious illness with high fatality. Clinical disease is infrequent among children. Infection during pregnancy is associated with a higher risk of symptomatic disease, severe liver injury, and mortality. Severe disease is also encountered in persons with preexisting chronic liver disease. Some cases have associated extrahepatic features, particularly acute pancreatitis and neurological manifestations. Chronic infection appears to be extremely infrequent with these HEV genotypes. The exact pathogenesis of liver injury remains unknown, although the host immune response appears to be important for viral clearance as well as for induction of liver injury. Hormonal and immune factors appear to be responsible for the severe disease during pregnancy.

Cholestasis induced liver pathology results in dysfunctional immune responses after arenavirus infection

Immune responses are critical for defense against pathogens. However, prolonged viral infection can result in defective T cell immunity, leading to chronic viral infection. We studied immune activation in response to arenavirus infection during cholestasis using bile duct ligation (BDL). We monitored T cell responses, virus load and liver pathology markers after infection with lymphocytic choriomeningitis virus (LCMV). BDL mice failed to induce protective anti-viral immunity against LCMV and consequently exhibited chronic viral infection. BDL mice exhibited reduced anti-viral T cell immunity as well as reduced type 1 interferon production early after LCMV infection. Consistently, the presence of serum from BDL mice reduced the responsiveness of dendritic cell (DC) and T cell cultures when compared to Sham controls. Following fractionation and mass spectrometry analyses of sera, we identified several serum factors to be upregulated following BDL including bilirubin, bile acids, 78 kDa Glucose regulated protein (GRP78) and liver enzymes. Bilirubin and GRP78 were capable of inhibiting DC and T cell activation. In this work, we demonstrate that liver damage mediated by cholestasis results in defective immune induction following arenavirus infection.

Hepatitis E, the neglected one

Hepatitis E virus (HEV) infection is a worldwide disease. It is the first cause of acute viral hepatitis in the world with an estimated 20 million cases every year and 56 000 deaths. In developing countries, hepatitis E is a waterborne infection. In these countries, HEV genotypes 1 and 2 cause large outbreaks and affect young subjects with a significant mortality rate in pregnant women and patients with cirrhosis. In the developed countries, HEV genotypes 3 and 4 are responsible for autochthonous, sporadic hepatitis and transmission is zoonotic. HEV can cause neurological disorders and in immunocompromised patients, chronic infections. The progression of acute hepatitis E is most often mild and resolves spontaneously. Diagnostic tools include anti-HEV IgM antibodies in serum and/or viral RNA in the blood or stools by PCR. Ribavirin is used to treat chronic infection. A vaccine has been developed in China.

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.

Clinical features and risk factors of acute hepatitis E with severe jaundice

AIM: To compares the clinical features of patients infected with hepatitis E virus (HEV) with or without severe jaundice. In addition, the risk factors for HEV infection with severe jaundice were investigated.

METHODS: We enrolled 235 patients with HEV into a cross-sectional study using multi-stage sampling to select the study group. Patients with possible acute hepatitis E showing elevated liver enzyme levels were screened for HEV infection using serologic and molecular tools.HEV infection was documented by HEV antibodies and by the detection of HEV-RNA in serum. We used χ² analysis, Fisher’s exact test, and Student’s t test where appropriate in this study. Significant predictors in the univariate analysis were then included in a forward, stepwise multiple logistic regression model.

RESULTS: No significant differences in symptoms, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, or hepatitis B virus surface antigen between the two groups were observed. HEV infected patients with severe jaundice had significantly lower peak serum levels of γ-glutamyl-transpeptidase (GGT) (median: 170.31 U/L vs 237.96 U/L, P = 0.007), significantly lower ALB levels (33.84 g/L vs 36.89 g/L, P = 0.000), significantly lower acetylcholine esterase (CHE) levels (4500.93 U/L vs 5815.28 U/L, P = 0.000) and significantly higher total bile acid (TBA) levels (275.56 μmol/L vs 147.03 μmol/L, P = 0.000) than those without severe jaundice. The median of the lowest point time tended to be lower in patients with severe jaundice (81.64% vs 96.12%, P = 0.000). HEV infected patients with severe jaundice had a significantly higher viral load (median: 134 vs 112, P = 0.025) than those without severe jaundice. HEV infected patients with severe jaundice showed a trend toward longer median hospital stay (38.17 d vs 18.36 d, P = 0.073). Multivariate logistic regression indicated that there were significant differences in age, sex, viral load, GGT, albumin, TBA, CHE, prothrombin index, alcohol overconsumption, and duration of admission between patients infected with acute hepatitis E with and without severe jaundice.

CONCLUSION: Acute hepatitis E patients may naturally present with severe jaundice.

Hepatitis E virus infection in developed countries

Hepatitis E was considered to be endemic infectious disease in developing countries in tropical or subtropical regions with poor sanitary conditions. Large, previously reported outbreaks were mainly due to contaminated water or heavy flooding. Prototype hepatitis E viruses of genotypes I and II were obtained from such endemic cases. In developed countries, in contrast, hepatitis E was rare and diagnosed only in travelers or imported cases. However, the development of accurate diagnostic tests, mainly PCR detection elucidated that autochthonous hepatitis E in developed countries is far more common than previously thought. Although the main route of transmission is food-borne, other routes including blood-borne have been suggested. Recent developments of gene-based diagnostic assays and molecular epidemiology have disclosed the significance of hepatitis E virus infection in developed countries.

Spectrum of Acute Viral Hepatitis in Southern India

BACKGROUND

The incidence of hepatitis-A among adults in India is on the decline as majority develops protective immunity to it by late adolescence. Most of these studies are from northern India. Clinical spectrum of sporadic acute viral hepatitis from southern India has not been well documented.

METHODS

A prospective hospital based study was conducted in a large military hospital in southern India. 224 consecutive patients with acute viral hepatitis were studied for their presentation, etiology and clinical features.

RESULT

Hepatitis-E was detected in 102 (45.4%), hepatitis A in 74 (33%) and hepatitis B in 28 (12.5%) patients. Acute hepatitis C was detected in two patients. 15 patients had a mixed infection. Hepatitis A constituted 41.2% and 31.3% of all cases in the age groups 11-20 and 21-30 years respectively. Cholestasis was present in 68 (30.4%) patients with hepatitis E accounting for most (61.8%) cases. There were four (1.8%) cases of acute liver failure. Two cases were due to hepatitis E and one case each was due to hepatitis A and hepatitis B. A relapsing course was seen in four cases due to hepatitis-A.

CONCLUSION

Hepatitis A remains a significant cause of sporadic acute viral hepatitis in young adults in southern India.

Hepatitis E virus-related cirrhosis in kidney- and kidney-pancreas-transplant recipients

Hepatitis E virus (HEV) infection was thought to be responsible for acute hepatitis that did not become chronic. However, we have recently reported that HEV infection can evolve to chronic hepatitis, at least in solid-organ transplant patients. We report on two cases of rapidly progressive of HEV-related cirrhosis that occurred in two organ-transplant patients. Case 1: A kidney-pancreas-transplant patient developed acute HEV hepatitis 60 months after transplantation, which evolved to chronicity as defined by persisting elevated liver-enzyme levels and positive serum HEV RNA. At 22 months after the acute phase, she presented with cirrhosis and portal hypertension, that is ascites and esophagus varices. Case 2: A kidney-transplant patient developed acute hepatitis 36 months after transplantation, which persisted and remained unexplained for 38 months. Then, HEV RNA was searched for in their serum and stools, and was found to be positive in both. Retrospective analysis of available stored serum, mainly the serum obtained at the acute phase, confirmed the diagnosis of chronic hepatitis E. In both cases, a liver biopsy showed cirrhosis. We conclude that HEV infection cannot only evolve to chronic hepatitis, but can also be responsible for rapidly progressing cirrhosis in organ-transplant patients.

Hepatitis E virus and chronic hepatitis in organ-transplant recipients

Hepatitis E virus (HEV) is considered an agent responsible for acute hepatitis that does not progress to chronic hepatitis. We identified 14 cases of acute HEV infection in three patients receiving liver transplants, nine receiving kidney transplants, and two receiving kidney and pancreas transplants. All patients were positive for serum HEV RNA. Chronic hepatitis developed in eight patients, as confirmed by persistently elevated aminotransferase levels, serum HEV RNA, and histologic features of chronic hepatitis. The time from transplantation to diagnosis was significantly shorter and the total counts of lymphocytes and of CD2, CD3, and CD4 T cells were significantly lower in patients in whom chronic disease developed.

Acute hepatitis E with severe jaundice: report of three cases

Hepatitis E virus (HEV) is the main cause of enterically transmitted non-A hepatitis worldwide. Infection is endemic in developing countries. Disease course is benign, and severe jaundice is rarely reported. Three patients presented to our department with symptomatic acute hepatitis. Two of them had recently travelled to endemic areas. Jaundice was very marked in all patients. HEV infection was documented by HEV antibodies and by HEV-RNA detection in serum and stools. In the autochthonous case, immunoglobulin-M was absent, and diagnosis was established on HEV-RNA amplification by real-time reverse transcriptase-PCR. Comprehensive investigation for concomitant causes of liver disease was negative in all patients. Histological features showed marked cholestasis with multiple bile plugs in dilated canaliculi. In conclusion, acute hepatitis E may be autochthonous in developed countries and patients may present with severe jaundice. HEV-RNA detection by real-time reverse transcriptase-PCR is a very efficacious diagnostic tool in anti-HEV immunoglobulin-M-negative cases.

Autochthonous hepatitis E in southwest England

Although autochthonous hepatitis E has been reported in developed countries, its extent and nature in the United Kingdom are unclear. The aim of the present study was to report the natural history, lifestyle risk factors and molecular epidemiology of autochthonous hepatitis E infection in southwest England. Three hundred and thirty-three patients with unexplained hepatitis were tested for markers of hepatitis E virus (HEV) infection over a 7-year period. HEV RNA isolated from the cases was amplified and characterized. Of the 333 patients, 21 had autochthonous hepatitis E. Patients were middle-aged or elderly and males were more commonly affected. Clinical manifestations ranged from asymptomatic infection to severe hepatitis. Of the 21 patients, 20 recovered within 6 weeks. None of the cases had travelled to an area endemic for HEV. None of the patients were vegetarian and all ate pork. Of the 21 cases, 20 occurred in the spring, summer and autumn months. All polymerase-chain-reaction-confirmed cases carried HEV genotype 3, which bore close sequence homology to HEV circulating in UK pigs. In the United Kingdom, autochthonous hepatitis E may be more common than previously recognized. Although the mode of transmission remains to be determined, it may be a zoonosis with pigs as a reservoir. Hepatitis E should be considered a public health issue in the United Kingdom.

Genetic variability and evolution of hepatitis E virus

Hepatitis E virus (HEV) is the sole member of the genus Hepevirus in the family Hepeviridae. HEV is transmitted primarily by the fecal-oral route, and water-borne epidemics are characteristic of hepatitis E in many developing countries in Asia, Africa and Latin America where sanitation conditions are suboptimal. Accumulating lines of evidence indicate that HEV-associated hepatitis also occurs domestically among individuals in industrialized countries, that there are animal reservoirs of HEV such as domestic pigs and wild boars, and that hepatitis E is a zoonosis. Based on the extensive genomic variability among HEV isolates, HEV sequences have been classified into four genotypes: genotype 1 consists of epidemic strains in developing countries in Asia and Africa; genotype 2 has been described in Mexico and several African countries; genotype 3 HEV is widely distributed and has been isolated from sporadic cases of acute hepatitis E and/or domestic pigs in many countries in the world, except for countries in Africa; and genotype 4 contains strains isolated from humans and/or domestic pigs exclusively in Asian countries. This paper reviews current knowledge on the genomic variability, geographic distribution and zoonotic aspects of HEV as well as the clinical significance of genotype and evolution of HEV.

Consumption of uncooked deer meat as a risk factor for hepatitis E virus infection: an age- and sex-matched case-control study

It was reported previously food-borne transmission of hepatitis E virus (HEV) to humans from deer meat. The present study attempted to clarify whether eating uncooked deer meat is a major epidemiological risk factor for HEV infection in Kasai, a city in western Japan. In total, 45 volunteer subjects with experience of eating raw deer meat were enrolled. An equivalent number of people from the same area who had never eaten raw deer meat served as controls. The subjects and controls had comparable age and sex distributions. Serum anti-HEV IgG and anti-hepatitis A virus (HAV) IgG levels were measured in all 90 volunteers. There was no significant difference in age, overseas travel history, or rate of anti-HAV antibody positivity between the subjects and controls. Eight (17.7%) of the subjects but only one (2.2%) of the controls had measurable serum anti-HEV IgG levels (P = 0.014). Anti-HAV prevalence did not differ between the anti-HEV-positive and negative groups. The results suggest that eating uncooked deer meat is an epidemiological risk factor for HEV infection in the studied area. In countries such as Japan where deer meat is sometimes eaten raw, attention must be paid to this route of HEV infection.

Infection of a Japanese patient by genotype 4 hepatitis e virus while traveling in Vietnam

Cases of imported hepatitis E in industrialized countries infected with a genotype 1 hepatitis E virus (HEV) have been identified. We report a 56-year-old Japanese man who acquired infection with a genotype 4 HEV with 98.8% identity to a Vietnamese isolate after ingestion of uncooked shellfish while traveling in Vietnam.

Sporadic acute or fulminant hepatitis E in Hokkaido, Japan, may be food-borne, as suggested by the presence of hepatitis E virus in pig liver as food

Among ten patients who contracted sporadic acute or fulminant hepatitis E between 2001 and 2002 in Hokkaido, Japan, nine (90 %) had a history of consuming grilled or undercooked pig liver 2-8 weeks before the disease onset. We tested packages of raw pig liver sold in grocery stores as food in Hokkaido for the presence of hepatitis E virus (HEV) RNA by RT-PCR. Pig liver specimens from seven (1.9 %) of 363 packages had detectable HEV RNA. Partial sequence analyses revealed that the seven swine HEV isolates belonged to genotype III or IV. One swine HEV isolate (swJL145) from a packaged pig liver had 100 % identity with the HE-JA18 isolate recovered from an 86-year-old patient in Hokkaido. Two swine HEV isolates (swJL234 and swJL325) had 98.5-100 % identity with the HE-JA4 isolate obtained from a 44-year-old patient in Hokkaido. These results indicate that inadequately cooked pig liver may transmit HEV to humans.

Cholestatic syndromes

Further insights into the molecular regulation of bile acid transport and metabolism have provided the basis for a better understanding of the pathogenesis of cholestatic liver diseases. Novel insights into the mechanisms of action of ursodeoxycholic acid should advance our understanding of the treatment of cholestatic liver diseases. Mutations of transporter genes can cause hereditary cholestatic syndromes in both infants and adults as well as cholesterol gallstone disease. Important studies have been published on the pathogenesis, clinical features, and treatment of primary biliary cirrhosis, drug-induced cholestasis, and cholestasis of pregnancy.