title: Superimposed acute hepatitis E infection in patients with chronic liver disease.
abstract: BACKGROUND
  The natural history of infection with hepatitis E virus (HEV) in patients with chronic liver disease (CLD) is not well described. Our study aims to document the presentation, course and outcome of HEV superinfection in patients with CLD.
  
  
  METHODS
  Over an 18-month period, ten patients with CLD were diagnosed to have HEV superinfection by detection of anti-HEV IgM antibodies in a setting of acute worsening. These patients were tested for HBsAg, IgM anti-HBc, anti-hepatitis C virus antibodies and IgM anti-hepatitis A virus antibodies, and were followed-up.
  
  
  RESULTS
  The etiology of underlying CLD in the 10 patients (9 men; mean [SD] age 42.4 [10.3] years) was alcohol in five patients, hepatitis B in two, hepatitis C in one and cryptogenic in two. Seven patients presented for the first time with recent-onset liver decompensation (median duration 27 days, range 7-45). All 10 had ascites and 7 had hepatic encephalopathy. Four patients developed renal failure during the course of illness. The median (range) bilirubin, ALT and albumin levels at presentation were 18.6 (4.9-32.6) mg/dL, 105 (28-6610) IU/L and 32 (29-41) g/L, respectively. At 8 weeks, only one patient had normalization of serum bilirubin or ALT levels. Three patients (30%) died, including two of renal failure and one of massive upper GI bleed.
  
  
  CONCLUSIONS
  Superinfection with HEV in patients with CLD causes severe liver decompensation, which is frequently complicated with hepatic encephalopathy and renal failure. Acute hepatitis E in these patients has a protracted course with high morbidity and mortality.
authors.affiliation: Department of Gastroenterology, G B Pant Hospital, New Delhi 110 002.
authors.forename: Rainish
authors.initials: R
authors.lastname: Monga
authors.forename: Sanjay
authors.initials: S
authors.lastname: Garg
authors.forename: Pankaj
authors.initials: P
authors.lastname: Tyagi
authors.forename: Nirmal
authors.initials: N
authors.lastname: Kumar
mesh_terms: D000328:Adult; D000368:Aged; D002908:Chronic Disease; D018450:Disease Progression; D005260:Female; D016751:Hepatitis E / Q000175:diagnosis / Q000453:epidemiology*; D006801:Humans; D007194:India / Q000453:epidemiology; D008103:Liver Cirrhosis / Q000150:complications* / Q000175:diagnosis; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D018570:Risk Assessment; D012494:Sampling Studies; D012720:Severity of Illness Index; D015163:Superinfection / Q000150:complications* / Q000175:diagnosis; D015996:Survival Rate