Transfusion-transmission of hepatitis E virus through red blood cell transfusion but not through platelet concentrates: A case report from Spain

BACKGROUND

Few cases of transfusion-transmitted hepatitis E virus (HEV) have been published in Spain. Here, we describe a well-characterized lookback investigation of a transfusion-transmitted HEV case at the Community Centre for Blood and Tissues of Asturias (Spain).

CASE REPORT

A female patient with chronic myeloid leukemia underwent an allogeneic bone marrow transplant in March 2019 and showed alterations in liver function shortly afterwards. This patient received blood components from 30 different donors in the 3 months before the transplant. Frozen plasma samples from these donations were investigated for the presence of HEV-RNA. One frequent donor was identified as asymptomatic HEV RNA-positive at the time of his whole blood donation. The investigation revealed that this donor's plasma unit, originally intended for the fractionation industry, had a viral RNA concentration of 1.9 × 104 copies/mL. HEV RNA was detected initially in the index patient who received the red cell concentrate from this donor 25 days after the transfusion. HEV RNA isolated from both donor and recipient were identified as subtype 3f. The recipient of platelet concentrate (PC), treated with a riboflavin-based pathogen reduction technology (PRT) was not infected, being negative for the presence of HEV IgM, IgG, and HEV RNA before and after the transfusion.

CONCLUSION

This case study shows that HEV was transmitted through red cell transfusion to a recipient, while the patient who received riboflavin/UV light treated PC did not develop signs of infection. A causal relationship between PRT treatment of the PC and the non-transmission of HEV remains to be established.

Hepatitis E as a cause of adult hospitalization in Bangladesh: Results from an acute jaundice surveillance study in six tertiary hospitals, 2014-2017

In the absence of reliable data on the burden of hepatitis E virus (HEV) in high endemic countries, we established a hospital-based acute jaundice surveillance program in six tertiary hospitals in Bangladesh to estimate the burden of HEV infection among hospitalized acute jaundice patients aged ≥14 years, identify seasonal and geographic patterns in the prevalence of hepatitis E, and examine factors associated with death.

We collected blood specimens from enrolled acute jaundice patients, defined as new onset of either yellow eyes or skin during the past three months of hospital admission, and tested for immunoglobulin M (IgM) antibodies against HEV, HBV and HAV. The enrolled patients were followed up three months after hospital discharge to assess their survival status; pregnant women were followed up three months after their delivery to assess pregnancy outcomes. From December’2014 to September’2017, 1925 patients with acute jaundice were enrolled; 661 (34%) had acute hepatitis E, 48 (8%) had hepatitis A, and 293 (15%) had acute hepatitis B infection. Case fatality among hepatitis E patients was 5% (28/589). Most of the hepatitis E cases were males (74%; 486/661), but case fatality was higher among females—12% (8/68) among pregnant and 8% (7/91) among non-pregnant women. Half of the patients who died with acute hepatitis E had co-infection with HAV or HBV. Of the 62 HEV infected mothers who were alive until the delivery, 9 (15%) had miscarriage/stillbirth, and of those children who were born alive, 19% (10/53) died, all within one week of birth. This study confirms that hepatitis E is the leading cause of acute jaundice, leads to hospitalizations in all regions in Bangladesh, occurs throughout the year, and is associated with considerable morbidity and mortality. Effective control measures should be taken to reduce the risk of HEV infections including improvements in water quality, sanitation and hygiene practices and the introduction of HEV vaccine to high-risk groups.

In the absence of reliable surveillance data on the burden of hepatitis E in endemic countries, we conducted a hospital-based acute jaundice surveillance study over a two and a half year period in six tertiary hospitals in Bangladesh. The study confirms that HEV infections occur throughout the year, and is a major (34%) cause of acute jaundice in tertiary hospitals in Bangladesh. Three-quarters of the acute hepatitis E cases were male, and HEV infection was higher among patients residing in urban areas than patients in rural areas (41% vs 32%). The overall case fatality rate of acute HEV infections in hospitals was 5%, but was higher among pregnant women (12%). Hepatitis E patients who died were more likely to have co-infection with HAV or HBV than the HEV infected patients who did not die. Fifteen percent of HEV infected mothers had miscarriage/stillbirth. Of the children who were born alive, 19% died, all within one week of birth. Considering the high burden of hepatitis E among hospitalized acute jaundice patients, Bangladesh could take control measures to reduce this risk including improvements in water quality, sanitation and hygiene practices and the introduction of hepatitis E vaccine in high-risk areas.

Hepatitis E and Allogeneic Hematopoietic Stem Cell Transplantation: A French Nationwide SFGM-TC Retrospective Study

Usually self-limited, hepatitis E virus (HEV) infection may evolve to chronicity and cirrhosis in immunosuppressed patients. HEV infection has been described in solid-organ transplantation and hematology patients, but for allogeneic hematopoietic stem cell transplant (alloHSCT) recipients, only small cohorts are available. This retrospective nationwide multi-center series aimed to describe HEV diagnostic practices in alloHSCT French centers, and the course of infection in the context of alloHSCT. Twenty-nine out of 37 centers participated. HEV search in case of liver function tests (LFT) abnormalities was never performed in 24% of centers, occasionally in 55%, and systematically in 21%. Twenty-five cases of active HEV infection were diagnosed in seven centers, all because of LFT abnormalities, by blood nucleic acid testing. HEV infection was diagnosed in three patients before alloHSCT; HEV infection did not influence transplantation planning, and resolved spontaneously before or after alloHSCT. Twenty-two patients were diagnosed a median of 283 days after alloHSCT. Nine patients (41%) had spontaneous viral clearance, mostly after immunosuppressive treatment decrease. Thirteen patients (59%) received ribavirin, with sustained viral clearance in 11/12 evaluable patients. We observed three HEV recurrences but no HEV-related death or liver failure, nor evolution to cirrhosis.

The Clinical Perspective on Hepatitis E

Every year, there are an estimated 20 million hepatitis E virus (HEV) infections worldwide, leading to an estimated 3.3 million symptomatic cases of hepatitis E. HEV is largely circulating in the west and is associated with several hepatic and extrahepatic diseases. HEV Genotype 1 and 2 infections are waterborne and causative for epidemics in the tropics, while genotype 3 and 4 infections are zoonotic diseases and are mainly transmitted by ingestion of undercooked pork in industrialized nations. The clinical course of these infections differs: genotype 1 and 2 infection can cause acute illness and can lead to acute liver failure (ALF) or acute on chronic liver failure (ACLF) with a high mortality rate of 20% in pregnant women. In contrast, the majority of HEV GT-3 and -4 infections have a clinically asymptomatic course and only rarely lead to acute on chronic liver failure in elderly or patients with underlying liver disease. Immunosuppressed individuals infected with genotype 3 or 4 may develop chronic hepatitis E, which then can lead to life-threatening cirrhosis. Furthermore, several extra-hepatic manifestations affecting various organs have been associated with ongoing or previous HEV infections but the causal link for many of them still needs to be proven. There is no approved specific therapy for the treatment of acute or chronic HEV GT-3 or -4 infections but off-label use of ribavirin has been demonstrated to be safe and effective in the majority of patients. However, in approximately 15% of chronically HEV infected patients, cure is not possible.

Severe haemolysis and renal failure precipitated by hepatitis E virus in G6PD Deficient patient: A case report

Hepatitis E virus is the etiological agent for Hepatitis E infection, which is congruent to Hepatitis A infection. The clinical spectrum of the disease range from asymptomatic self-limiting disease which requires no treatment to life threatening fulminant liver disease in pregnancy, G6PD deficient and post-liver transplant patients, which necessitate urgent treatment. Similarly we are reporting a case of a 28 year old male with no previous known comorbids, who presented in emergency department with low grade fever, yellow discolouration of eyes and upper abdominal pain for last 5-6 days. We affirmed the diagnosis of acute viral hepatitis E with G6PD deficiency. This case had a different prospect of HEV infection and its coexistence with G6PD deficiency, which lead to investigations, management and avoidance of complications of the disease.

Hepatitis E virus: advances and challenges

At least 20 million hepatitis E virus (HEV) infections occur annually, with >3 million symptomatic cases and ∼60,000 fatalities. Hepatitis E is generally self-limiting, with a case fatality rate of 0.5-3% in young adults. However, it can cause up to 30% mortality in pregnant women in the third trimester and can become chronic in immunocompromised individuals, such as those receiving organ transplants or chemotherapy and individuals with HIV infection. HEV is transmitted primarily via the faecal-oral route and was previously thought to be a public health concern only in developing countries. It is now also being frequently reported in industrialized countries, where it is transmitted zoonotically or through organ transplantation or blood transfusions. Although a vaccine for HEV has been developed, it is only licensed in China. Additionally, no effective, non-teratogenic and specific treatments against HEV infections are currently available. Although progress has been made in characterizing HEV biology, the scarcity of adequate experimental platforms has hampered further research. In this Review, we focus on providing an update on the HEV life cycle. We will further discuss existing cell culture and animal models and highlight platforms that have proven to be useful and/or are emerging for studying other hepatotropic (viral) pathogens.

Hepatitis E: Discovery, global impact, control and cure

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

Epidemiology of hepatitis E virus in Iran

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

[Hepatitis E--overview of the latest knowledge]

Hepatitis E (HE) is a ubiquitous infection, occurring both in developing and in developed countries. It is caused by the hepatitis E virus (HEV), a small, non-enveloped RNA virus. The reported incidence in the Czech Republic in 2013 was 2 cases per 100,000 inhabitants and the number of HE cases has been growing over the past years. Besides the long known fecal-oral transmission, zoonotic and blood product transmission of HEV has recently been observed in industrialized countries. Most infections are asymptomatic. Symptomatic infection may present as acute hepatitis with nonspecific flu-like symptoms and liver enzymes elevation. In immunocompromised patients, HEV can lead to chronic hepatitis E and can even cause acute liver failure in pregnant women. Several extrahepatic manifestations have also been reported. Antiviral therapy has been successfully used in chronic hepatitis E. The first vaccine available for clinical use is licensed in China so far.

Frequency and prognosis of acute pancreatitis associated with acute hepatitis E: A systematic review

BACKGROUND

The association of acute pancreatitis (AP) with viral hepatitis is well known, and is usually attributed to HAV, HBV, or HCV. AP related to acute hepatitis E (AHE) has been rarely described, and the typical profile is that of a young male, residing in an endemic area, presenting with mild to moderate pancreatitis, and improving with conservative management.

RATIONALE

An increasing number of reports describe AP associated with AHE. Some life-threatening complications related to AP may occur, and death has been reported. In addition, it is possible that early diagnosis of these cases may help in reducing the morbidity and mortality.

OBJECTIVE

Perform a systematic review to study cases of AP associated with AHE and to assess their prognosis.

DATA SOURCES

PubMed, EMBASE, Scopus, and the Cochrane library.

STUDY SELECTION

All available studies discussing AP associated with AHE.

DATA EXTRACTION AND ASSESSMENT

Two blinded independent observers extracted and assessed the studies for diagnosis of AHE based on serological and/or molecular techniques, diagnosis of fulminant hepatitis based on the American Association for the study of Liver Diseases (AASLD) position paper, diagnosis of AP based on the American College of Gastroenterology (ACG) guidelines, diagnosis of AP associated with AHE based on Makharia's association, and diagnosis of AP severity based on the Revision of the Atlanta Classification (RAC).

RESULTS

Thirteen case reports and 4 case series were found with 55 patients meeting the inclusion criteria. All patients originated from Southern Asia or had a recent travel to that area. The mean age at diagnosis was 28 years with a male to female ratio of 18:1. The mean interval between the onset of jaundice and the onset of AP pain was 10 days. AP was mild or moderately severe in 45 patients (82%), and severe in 10 patients (18%). Mortality was reported in 2 patients (3.6%).

CONCLUSION

Fifty-five cases of acute pancreatitis associated with AHE are reported in the literature. Acute pancreatitis in this setting is severe in approximately one fifth of patients with an overall mortality rate similar to all other causes of AP.

Influence of chronic HBV infection on superimposed acute hepatitis E

AIM: To investigate the influence of chronic hepatitis B virus (HBV) infection [based on the status of hepatitis B e antigen (HBeAg), HBV DNA, and cirrhosis] on superimposed acute hepatitis E.

METHODS: A total of 294 patients were recruited from the Department of Infectious Diseases of the Third Affiliated Hospital, Sun Yat-sen University, from January 2003 to January 2012. The patients were classified into two groups: an HBV + hepatitis E virus (HEV) group (a group with chronic HBV infection that was superinfected with acute hepatitis E, n = 118) and an HEV group (a group with acute hepatitis E, n = 176). We retrospectively analyzed and compared the clinical features of the two groups. Statistical analyses were performed using the χ² test or Fisher’s exact test for categorical variables and the Student’s t test for continuous variables. A P value < 0.05 was considered statistically significant.

RESULTS: The peak values of prothrombin time, serum total bilirubin, and Model for End-Stage Liver Disease scores were significantly higher in the HBV + HEV group. More patients in the HBV + HEV group had complications (39.8% vs 16.5%, P = 0.000) and developed liver failure (35.6% vs 8.5%, P = 0.000). Additionally, the mortality of the HBV + HEV group was significantly higher (20.3% vs 7.4%, P = 0.002). Further analysis of the HBV + HEV group showed that there were no significant differences in complication occurrence, liver failure incidence, or mortality between patients with different HBeAg and HBV DNA statuses. However, in patients with underlying cirrhosis, complication occurrence and liver failure incidence significantly increased. In total, 12.7% of the patients in the HBV + HEV group received anti-HBV treatment, but this therapy failed to reduce mortality in patients who developed liver failure.

CONCLUSION: The presence of underlying cirrhosis in chronic HBV infection results in more severe clinical outcomes with superimposed acute hepatitis E. Anti-HBV treatment cannot improve the prognosis of liver failure caused by HBV-HEV superinfection.

[An update on hepatitis E]

The hepatitis E virus (HEV) is an RNA virus transmitted via the fecal-oral route or through uncooked animal meat products. Of the 4 known genotypes, genotype 3 is responsible for autochthonous infections in industrialized countries, with a seroprevalence in Switzerland estimated as high as 22%. The majority of infections is asymptomatic but a minority of patients, notably men over 50 or with underlying liver disease, can present with severe acute hepatitis. Chronic hepatitis E with HEV of genotype 3 has been observed in immunosuppressed patients, mostly transplant recipients. Serology is not sufficiently sensitive, especially in immunosuppressed patients, making PCR identification the preferred test for diagnosing active infection. Ribavirin or interferon-alpha can be used to treat chronic hepatitis E if reduction of immunosuppressive treatment does not result in viral elimination.

Hepatitis E

Hepatitis E virus (HEV) was discovered during the Soviet occupation of Afghanistan in the 1980s, after an outbreak of unexplained hepatitis at a military camp. A pooled faecal extract from affected soldiers was ingested by a member of the research team. He became sick, and the new virus (named HEV), was detected in his stool by electron microscopy. Subsequently, endemic HEV has been identified in many resource-poor countries. Globally, HEV is the most common cause of acute viral hepatitis. The virus was not initially thought to occur in developed countries, but recent reports have shown this notion to be mistaken. The aim of this Seminar is to describe recent discoveries regarding HEV, and how they have changed our understanding of its effect on human health worldwide.

Cytokine profiles, CTL response and T cell frequencies in the peripheral blood of acute patients and individuals recovered from hepatitis E infection

Background

Hepatitis E is a major public health problem in the developing countries. Pathogenesis of hepatitis E virus (HEV) infection is poorly understood.

Methods

This case-control study included 124 Hepatitis E patients (46 acute and 78 recovered), 9 with prior exposure to HEV and 71 anti-HEV negative healthy controls. HEV induced CTL response by Elispot, cytokines/chemokines quantitation by Milliplex assay and peripheral CD4+ & CD8+ T cell frequencies by flow cytometry were assessed.

Results

Among the patient categories, HEV specific IFN-γ responses as recorded by Elispot were comparable. Comparisons of cytokines/chemokines revealed significantly high levels of IL-1α and sIL-2Rα during acute phase. Circulating peripheral CD4/CD8+ T-cell subsets in acute and recovered individuals were comparable compared to controls, while among patient categories CD8+T cell subset was significantly higher in recovered individuals.

Conclusions

Our findings suggest that IL-1α and sIL-2Rα play a role in the pathogenesis of acute Hepatitis E infection. Lack of robust HEV ORF2-specific CTL response in the peripheral blood of HEV infected patients during the acute and recovered phases of the disease may be associated with involvement of innate immune cells/localization of the immune events at the site of infection.

[Hepatitis E virus: zoonotic implications]

The Hepatitis E virus (HEV) is transmitted primarily by the feco-oral route throughout contaminated water and/or food, and is one of the main causes of acute hepatitis worldwide. Hepatitis E shows a high mobility but a low mortality rate, except in pregnant women, where it can be as high as 30%. HEV causes sporadic cases and epidemic outbreaks, mainly in Africa, Asia and Central America. In Europe, there is an increase in the number of reported autochthonous cases no related with travel to endemic areas. In addition, HEV also infects animals, including pigs, and its zoonotic potential has been recently demonstrated. In fact, porcine and human strains of the same area are genetically more closely related to each other than to strains of the same species but a different geographical region, and there are data suggesting that people in close contact with pigs presents a higher prevalence of specific anti-HEV antibodies. All together, these data have drove to an increase interest in determining the incidence of the disease in animals, its possible zoonotic risk, and its implications for human health. In the present article we revised the current knowledge about HEV, with special emphasis in the possible consequences of its zoonotic potential.

Acute liver failure caused by hepatitis E virus and paracetamol

Acute liver failure is characterized by severe and sudden liver cell dysfunction leading to hepatic encephalopathy and hepatic coagulopathy in a person without history of liver disease in the past. This catastrophic illness can rapidly progress to coma and death from cerebral edema and multi organ dysfunction. It carries a high mortality rate if liver transplantation is not carried out. In West, paracetamol is the main cause of hepatotoxicity whereas in the East viral hepatitis tops the list. This report describes a case of acute liver failure in which probably both the agents were involved. The patient recovered with antidote therapy and maximum supportive care.

[A case of fulminant hepatitis E treated with artificial liver support]

A 40-year-old man, who had suffered from general malaise and brown urine during his stay in China, was admitted with remarkable jaundice and hepatocellular disorders soon after he returned to Japan. Because his coagulation test results worsened, he was transferred to our hospital. No evidence of hepatitis A-D virus infection, autoimmune hepatitis, or metabolic disorders was noticed. His prothrombin time was extended (18%), grade II encephalopathy appeared on the second hospital day, and fulminant hepatitis was diagnosed. Artificial liver support was introduced, and his hepatic coma and coagulation parameters gradually recovered. Genotype IV hepatitis E virus RNA was detected in his early phase sera and also both IgG and IgM type anti-hepatitis E virus antibodies were detected. Fulminant hepatitis E resulting from infection in China was diagnosed.

Hepatitis E in Nepal

Hepatitis E is an acute disease caused by hepatitis E virus that usually manifest as acute jaundice. The hallmark of the disease is its high incidence in young adults, and high mortality in pregnant women from acute hepatic failure. It is a waterborne infection and occurs sporadically or as epidemic outbreaks. Kathmandu valley is a hyper-endemic area for hepatitis E, where during last 30 years three large epidemics and many focal outbreaks have occurred. About 50% of the sporadic cases of acute hepatitis in Kathmandu valley are caused by hepatitis E. This paper describes the epidemiology hepatitis E in Nepal, and its clinical features and management.

[Hepatitis A and E enterically transmitted virus infections of the liver]

Hepatitis A virus (a picornavirus) and hepatitis E virus (so far unclassified) are small, non-enveloped and relatively stable RNA viruses with many similar, yet, not identical characteristics. Both viruses are transmitted preferentially by the fecal-oral route. Consequently, their spread is favoured by poor personal hygiene and inappropriate sanitary conditions. Infection can pass subclinically, take an acute and self limiting course, and can also manifest as fulminant hepatitis with liver failure. True chronic disease is unknown. Laboratory diagnosis is preferentially performed by serology, but can also be complemented by assay for viral RNA in stool or serum. Resolution of infection leads to immunity which, in the case of hepatitis A, is known to be fully protective and most likely lifelong. Available hepatitis A vaccines are able to induce a similar state of protection. Vaccines for hepatitis E are under development. Specific antiviral treatment is not yet available, neither for hepatitis A nor for hepatitis E.

Frequency and clinical course of hepatitis E in tertiary care hospitals

OBJECTIVE

To find out the frequency of hepatitis E virus as a cause of acute hepatitis and its clinical course in hospitalized patients.

DESIGN

Cross-sectional hospital-based study.

PLACE AND DURATION OF STUDY

The study was conducted in two tertiary care teaching hospitals i.e., Khyber Teaching Hospital and PGMI Lady Reading Hospital, Peshawar (Pakistan) from January to December 2002.

PATIENTS AND METHODS

Amongst the total number of 1922 admitted patients, 148 had history of nausea, vomiting and jaundice and raised serum bilirubin with raised hepatic transaminases (ALT), were screened for HBV (hepatitis B virus), HCV (hepatitis C virus) and subsequently for HEV (hepatitis E virus). Acute hepatitis A, autoimmune hepatitis and Wilson's disease were excluded by doing appropriate test as and when required. The patients with hepatitis E were then monitored by checking their serial transaminases on day 1,4,8 and day 18 or until their transaminases dropped to normal. They were also clinically assessed and followed-up.

RESULTS

Amongst the total admission of 1922 patients during one year period, 148 had acute hepatitis and out of these, 21 patients (14.189%) suffered from hepatitis E. Seventeen patients were below the age of 40. There were increased number of cases during the late summer and early winter seasons. Majority of the hepatitis E patients recovered during the short follow-up period of two weeks. Two patients had fulminant hepatitis. A four months pregnant young female died of her illness despite intensive treatment.

CONCLUSION

Hepatitis E virus is fairly common cause of acute hepatitis in hospitalized patients. Most of the patients are having a benign self-limiting illness.

[Hepatitis and pregnancy--a short review]

Viral hepatitis is one of the most serious infections in pregnant women. There are now at least five hepatitis viruses. This educational review describes the various types of hepatitis, clinical manifestations, their impact on mother and fetus, prevention and treatment options, risks of perinatal transmission and differential diagnosis. Several open questions regarding vaccination as well as perinatal transmission have been addressed.

Hepatitis E virus

Hepatitis E virus (HEV) is a positive-stranded RNA virus with a 7.2 kb genome that is capped and polyadenylated. The virus is currently unclassified: the organisation of the genome resembles that of the Caliciviridae but sequence analyses suggest it is more closely related to the Togaviridae. Hepatitis E virus is an enterically transmitted virus that causes both epidemics and sporadic cases of acute hepatitis in many countries of Asia and Africa but only rarely causes disease in more industrialised countries. Initially the virus was believed to have a limited geographical distribution. However, serological studies suggest that HEV may be endemic also in the United States and Europe even though it infrequently causes overt disease in these countries. Many different animal species worldwide recently have been shown to have antibodies to HEV suggesting that hepatitis E may be zoonotic. Although two related strains have been experimentally transmitted between species, direct transmission from an animal to a human has not been documented. There are four currently recognised genotypes and two of the four contain viruses isolated from swine as well as from humans. Regardless of country of origin or genotype of the virus, most, if not all, strains belong to a single serotype. A promising recombinant vaccine candidate comprised of a truncated capsid protein is currently under evaluation in Nepal.

Successful rescuing a pregnant woman with severe hepatitis E infection and postpartum massive hemorrhage

AIM: To sum up the experience of the successful therapy for the severe hepatitis of pregnant woman with postpartum massive hemorrhage.

METHODS: The advanced therapeutic methods including the bilateral uterine artery embolism, hemodialysis and artificial liver support therapy were performed with comprehensive medical treatments and the course of the successful rescuing the patient was analyzed.

RESULTS: Through the hospitalization of about two mouths the patient and her neonatus had gotten the best of care in our department and pediatric department separately. Both of them were discharged in good condition.

CONCLUSION: The key points for a successful therapy of the pregnant woman with severe hepatitis are termination of the pregnancy and the control of their various complications. It was suggested that the proper combination of these measures of modern therapy would race against time for renewing of hepatic and renal functions.

New perspectives on hepatitis E

The infectious agent causing epidemic non-A, non-B hepatitis was identified in 1983 from a human challenge experiment. The novel hepatitis E virus (HEV) subsequently was cloned in 1990 and the genome sequenced. HEV transmission is highly endemic in Asia, the Middle East, and Africa. Fecal contamination of drinking water is the most common mode of spread. Although usually asymptomatic, HEV infection can cause fulminant hepatitis. Recent studies indicate that hepatitis E may be a zoonotic disease, with pigs and possibly rats serving as reservoirs for human infection. A recombinant HEV vaccine is currently in phase III clinical trials. The characterization of the major types of viral hepatitis during the last 20 years illustrates how modern genetic technology has revolutionized research in infectious diseases. Within less than two decades of the discovery of HEV, its epidemiology has been described, serologic tests have been developed, and a candidate vaccine has been evaluated in clinical trials.

Typhoid, hepatitis E, or typhoid and hepatitis E: the cause of fulminant hepatic failure--a diagnostic dilemma

OBJECTIVE

To report a case of hepatitis E-induced fulminant hepatic failure associated with typhoid fever, diagnosed with the Widal test.

DESIGN

Case report.

SETTING

Eight-bed medical/surgical intensive care unit of a university hospital.

PATIENT

A 15-yr-old, 50-kg male with grade IV hepatic encephalopathy was admitted to the intensive care unit for ventilatory support. On admission to the intensive care unit he had had fever associated with loss of appetite and nausea for 15 days, jaundice for 4 days, and altered sensorium for 2 days.

INTERVENTION

He was intubated and kept on elective ventilation. Tracheal aspirate, blood, urine, and stool were sterile. Anti-coma measures were instituted in the form of 20 degrees head elevation; mannitol, lactulose, and ampicillin through a nasogastric tube; and bowel wash. The mainstay of fluid therapy was 20% dextrose. Viral marker was positive for hepatitis E. He showed a favorable recovery but continued to have high-grade fever (39-40 degrees C). On investigation, peripheral blood smear was negative for malarial parasite, and Widal was positive. Fever responded to treatment with Ceftazidime.

RESULT

The patient recovered with anti-coma and anti-typhoid therapy.

CONCLUSION

In viral hepatitis, fever is usually present in the prodromal phase but subsides before appearance of the icteric phase. In endemic areas, if fever is present in the icteric phase of hepatitis, typhoid also should be considered in the differential diagnosis of fever, even in the absence of positive cultures for Salmonella typhi. The Widal test may be helpful in reaching a diagnosis.

Severe acute pancreatitis in acute hepatitis E

We report an 18-year-old boy with severe acute pancreatitis developing during acute hepatitis E and complicated by sepsis and acute renal failure. The patient recovered on supportive management.

Hepatitis E

Hepatitis E, previously known as enterically transmitted non-A, non-B hepatitis, is an infectious viral disease with clinical and morphologic features of acute hepatitis. Its causative agent, hepatitis E virus, consists of small, 32- to 34-nm diameter, icosahedral, nonenveloped particles with a single-stranded, positive-sense, 7.5-kb RNA. The virus has two main geographically distinct strains, Asian and Mexican; recently, novel isolates from nonendemic areas and a genetically related swine HEV have been described. HEV is responsible for large epidemics of acute hepatitis and a proportion of sporadic hepatitis cases in the Indian subcontinent, southeast and central Asia, the Middle East, parts of Africa, and Mexico. The virus is excreted in feces and is transmitted predominantly by fecal-oral route, usually through contaminated water. Person-to-person transmission is uncommon. Clinical attack rates are the highest among young adults. Recent evidence suggests that humans with subclinical HEV infection and animals may represent reservoirs of HEV; however, further data are needed. Diagnosis of hepatitis E is usually made by detection of specific IgM antibody, which disappears rapidly over a few months; IgG anti-HEV persists for at least a few years. Clinical illness is similar to other forms of acute viral hepatitis except in pregnant women, in whom illness is particularly severe with a high mortality rate. Subclinical and unapparent infections may occur; however, chronic infection is unknown. No specific treatment is yet available. Use of clean drinking water and proper sanitation is currently the most effective method of prevention. Passive immunization has not been proved to be effective, and recombinant vaccines for travelers to disease-endemic areas and for pregnant women currently are being developed.

Acute and chronic viral hepatitis

Viral hepatitis is the most common cause of acute and chronic hepatitis. The term viral hepatitis generally refers to infections resulting from one of the hepatotrophic viruses: hepatitis A, B, C, D, and E. The last 10 years have brought many important advances in understanding the epidemiology, pathogenesis, molecular biology, and immunoprophylaxis of infections caused by hepatotrophic viruses. Development of sensitive and specific immunoassays has enabled detection of specific agents. This has allowed for identification of infected patients and monitoring response to therapy. Additionally, serologic markers have allowed for isolation of contaminated blood products and a reduction in the spread of disease. The remaining challenge is the application of this knowledge to the treatment and prevention of viral hepatitis. This article explores the risk factors, epidemiology, microbiology, clinical and laboratory diagnosis, treatment, and prevention of the hepatotrophic viral infections.

Hepatitis E in India

Institute of Pediatric Gastroenterology is superspecialised referral institute for all Pediatric Gastroenterological diseases from all over the country and for adjoining countries. We have our data and experience on 10,500 cases of proven Hepatitis E (HEV) in Pediatric population. HEV is non-enveloped 27-30 nm diameter RNA virus, prototype for alpha-like supergroup of positive stranded RNA virus. Indian HEV strain has 97% nucleotide and 98% amino acid sequence identity with Chinese strains but much diversity with Mexican strain. More than 70% acute hepatitis occurring in Pediatric population in this subcontinent are caused by HEV and 80% of these are sporadic. 90% cases were enterically transmitted, spread primarily by fecally contaminated drinking water (70%) and by food (20%), in 9.5% case spread probably was because of person to person and household contact. We could demonstrate HEV in urine, respiratory secretions. Interestingly we found HEV in insects like Flies, Cockroaches, and also in engorged Bedbugs and in Mosquitoes, apart from briefly boiled Mussels, and partially cooked cockles. Maternal-neonatal transmission could be seen if mother had HEV infection in third trimester of pregnancy. In 5 cases we could demonstrate HEV in breast milk. By studying on 10 volunteers, 40% have anicteric form only accompanied by anorexia, epigastric pain. HEV appeared in serum before the icteric phase. Shedding of virus in stool starts before the icteric phase and continued during the high levels of abnormal ALT. Hepatitis IgG anti-HEV persist up to 4 years. In 5 cases we could establish Transfusion associated Hepatitis (TAH). No chronicity could be documented. 5% cases had fulminant viral Hepatitis (FVH)/Sub fulminant viral Hepatitis (SVH), alpha-interferon (IFN) has been proved beneficial in these cases, further use of intravenous PGEl could also be beneficial. Inadequate chlorination of drinking water was an important additional factor for causing epidemics. A free residual chlorine concentration of at least 0.5 mg/l for minimum of 30 minutes is considered adequate as quality of drinking water.

Tropical aspects of viral hepatitis. Hepatitis E

Hepatitis E (HEV) is a faeco-orally transmitted hepatitis virus. It has many features similar to hepatitis A but some differences, notably the high mortality caused by HEV in pregnant women. A vaccine is being developed but at the moment only a clean water supply will reduce the number of cases in areas where the virus is endemic.

[Clinical analysis of 39 cases of hepatitis E in pregnancy]

OBJECTIVE

To introduce clinical manifestations and treatment of hepatitis E in pregnancy.

METHODS

Thirty-nine cases of hepatitis E in pregnancy, were analysed from June. 1992 to Jun. 1994, retrospectively on its epidemiologic characteristics, clinical manifestations and prognosis.

RESULTS

The prognosis of sporadic cases of hepatitis E in pregnancy was good and its main complications were premature rupture of membranes, uterine inertia and fetal distress.

CONCLUSIONS

Sporadic case is the main form of hepatitis E in pregnancy in Beijing. Active treatment and intensive monitoring would improve its prognosis.