title: Chronic hepatitis E virus infection in a patient with leukemia and elevated transaminases: a case report.
abstract: BACKGROUND
  Acute hepatitis E virus infection may cause mild, self-limiting hepatitis, either as epidemic outbreaks or sporadic cases, the latter of which have been reported in industrialized countries. Chronic infections are uncommon and have been reported in immunosuppressed patients, patients with human immunodeficiency virus infection, and patients with hematological malignancies.
  
  
  METHODS
  A 46-year-old Caucasian man was admitted to the gastroenterology clinic with a history of increasing transaminases, persistent exhaustion, and occasional right-side abdominal pain over the course of a 6-month period. B-cell chronic lymphocytic leukemia had been diagnosed several years earlier, and the patient was treated with rituximab, pentostatin, and cyclophosphamide. A diagnostic workup ruled out autoimmune and metabolic liver disease, hepatitis A-C, and herpes virus infection. A physical examination revealed enlarged axillary lymph nodes. The results of an abdominal ultrasound examination were otherwise unremarkable. Hepatitis E virus infection was diagnosed by detection of hepatitis E virus-specific antibodies. Blood samples were positive for hepatitis E virus ribonucleic acid with high viral loads for at least 8 months, demonstrating a rare chronic hepatitis E virus infection. Sequencing and phylogenetic analysis revealed hepatitis E virus genotype 3c with homologies to other European isolates from humans and swine, indicating an autochthonous infection.
  
  
  CONCLUSIONS
  Usually, hepatitis E virus infection appears as an acute infection; rare chronic infections have been reported for transplant patients, patients with human immunodeficiency virus, and patients with hematological malignancies. The chronic nature of hepatitis E infection in our patient was most likely induced by the immunosuppressive B-cell chronic lymphocytic leukemia treatment. The differential diagnosis in patients with unexplained hepatitis should include hepatitis E virus infection, and appropriate laboratory analyses should be considered.
authors.affiliation: Department of Infectious Diseases, Virology, University of Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany. paul_schnitzler@med.uni-heidelberg.de.
authors.forename: Annika
authors.initials: A
authors.lastname: Gauss
authors.forename: Juergen J
authors.initials: JJ
authors.lastname: Wenzel
authors.forename: Christa
authors.initials: C
authors.lastname: Flechtenmacher
authors.forename: Mojdeh Heidary
authors.initials: MH
authors.lastname: Navid
authors.forename: Christoph
authors.initials: C
authors.lastname: Eisenbach
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Jilg
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Stremmel
authors.forename: Paul
authors.initials: P
authors.lastname: Schnitzler