Acute Hepatitis E Virus infection with coincident reactivation of Epstein-Barr virus infection in an immunosuppressed patient with rheumatoid arthritis: a case report.
BACKGROUND
Hepatitis E virus (HEV) is the most recently discovered of the hepatotropic viruses, and is considered an emerging pathogen in developed countries with the possibility of fulminant hepatitis in immunocompromised patients. Especially in the latter elevated transaminases should be taken as a clue to consider HEV infection, as it can be treated by discontinuation of immunosuppression and/or ribavirin therapy. To our best knowledge, this is a unique case of autochthonous HEV infection with coincident reactivation of Epstein-Barr virus (EBV) infection in an immunosuppressed patient with rheumatoid arthritis (RA).


METHODS
A 68-year-old Swiss woman with RA developed hepatitis initially diagnosed as methotrexate-induced liver injury, but later diagnosed as autochthonous HEV infection accompanied by reactivation of her latent EBV infection. She showed confounding serological results pointing to three hepatotropic viruses (HEV, Hepatitis B virus (HBV) and EBV) that could be resolved by detection of HEV and EBV viraemia. The patient recovered by temporary discontinuation of immunosuppressive therapy.


CONCLUSIONS
In immunosuppressed patients with RA and signs of liver injury, HEV infection should be considered, as infection can be treated by discontinuation of immunosuppression. Although anti-HEV-IgM antibody assays can be used as first line virological tools, nucleic acid amplification tests (NAAT) for detection of HEV RNA are recommended--as in our case--if confounding serological results from other hepatotropic viruses are obtained. After discontinuation of immunosuppressive therapy, our patient recovered from both HEV infection and reactivation of latent EBV infection without sequelae.
Center of Laboratory Medicine, Frohbergstrasse 3, 9001, St. Gallen, Switzerland. detlev.schultze@zlmsg.ch.
Detlev
D
Schultze
Center of Laboratory Medicine, Frohbergstrasse 3, 9001, St. Gallen, Switzerland. bernhard.mani@zlmsg.ch.
Bernhard
B
Mani
Center of Laboratory Medicine, Frohbergstrasse 3, 9001, St. Gallen, Switzerland. guenter.dollenmaier@zlmsg.ch.
Günter
G
Dollenmaier
Institute of Microbiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 48, 1011, Lausanne, Switzerland. roland.sahli@chuv.ch.
Roland
R
Sahli
Institute of Medical Virology, Winterthurerstrasse 190, 8057, Zürich, Switzerland. zbinden.andrea@virology.uzh.ch.
Andrea
A
Zbinden
Spital Linth, Gasterstrasse 25, 8730, Uznach, Switzerland. pierre-alexandre.krayenbuehl@spital-linth.ch.
Pierre Alexandre
PA
Krayenbühl
D000368:Aged; D001172:Arthritis, Rheumatoid / Q000276:immunology / Q000821:virology*; D060085:Coinfection; D020031:Epstein-Barr Virus Infections / Q000175:diagnosis* / Q000188:drug therapy; D005260:Female; D006508:Hepatitis Antibodies / Q000097:blood; D006515:Hepatitis B virus / Q000276:immunology / Q000472:pathogenicity; D016751:Hepatitis E / Q000188:drug therapy / Q000821:virology*; D004854:Herpesvirus 4, Human / Q000276:immunology / Q000472:pathogenicity; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D012254:Ribavirin / Q000627:therapeutic use
D006508:Hepatitis Antibodies; D007166:Immunosuppressive Agents; D012254:Ribavirin