title: Persistent Hepatitis E Infection in a Patient with Tuberous Sclerosis Complex Treated with Everolimus: A Case Report.
abstract: BACKGROUND
  The incidence of hepatitis E (HEV) genotype 3 is rising in developed countries. HEV infections are usually self-limiting, but can become chronic in immunocompromised patients. This might lead to rapid fibrosis development even resulting in cirrhosis. Chronic HEV is mainly described in patients after solid-organ or hematological transplantations. We present the first case of HEV infection in a patient with tuberous sclerosis complex (TSC) treated with everolimus, a mammalian target of rapamycin (mTOR) inhibitor.
  
  
  METHODS
  A 46-year-old male with TSC was referred to the infectious diseases department with an acute rise of liver enzymes during routine laboratory check-up. He was diagnosed with an acute HEV infection. His current treatment for TSC was everolimus. After awaiting a spontaneous clearance for 3 months, everolimus was discontinued. Hereafter, the infection was cleared within another 3 months.
  
  
  CONCLUSIONS
  Due to a favorable side-effect profile, everolimus is gaining popularity as an immunosuppressive therapy. However, in vitro experiments suggest that inhibition of mTOR leads to a significant increase in HEV replication. Thus far, there have been no clinical reports of HEV infections in patients treated with everolimus.
  
  
  CONCLUSIONS
  Due to higher dosing of everolimus in TSC patients, they are more vulnerable to the development of chronic HEV infection. Periodic assessment of transaminases in these patients is advised.
authors.affiliation: Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Wobke E M
authors.initials: WEM
authors.lastname: van Dijk
authors.affiliation: Department of Internal Medicine and Endocrinology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Menno A M H
authors.initials: MAMH
authors.lastname: Vergeer
authors.affiliation: Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands. j.e.arends@umcutrecht.nl.
authors.forename: Joop E
authors.initials: JE
authors.lastname: Arends
keywords: Chronic hepatitis E; Everolimus; Hepatitis E; Tuberous sclerosis complex; mTOR-inhibitor