Acute Hepatitis E Presenting as Autoimmune Hepatitis

Abstract

Introduction: Hepatitis E virus (HEV) generally causes a self-limited acute infection, although fulminant hepatitis can develop. Chronic infection can be seen in transplant and immunosuppressed patients. HEV is the second most common cause of sporadic hepatitis in the Middle East and North Africa. We discuss a case of acute HEV infection presenting as autoimmune hepatitis (AIH). Case Report: 32 year-old male with history of diabetes mellitus, hypertension and hyperlipidemia admitted to our institution for jaundice and fatigue. Patient returned back from Dubai about a month prior to the onset of his symptoms. He denied use of new medications and herbal supplements. Physical examination was remarkable for scleral icterus. The lab results revealed AST/ALT 642/1249 while ALP/GGT 152/235, protein/albumin 8.9/4.2, antinuclear antibodies 1280 and IgG 3590. Hepatitis serology positive for HEV IgM and negative for hepatitis A, B and C. Liver biopsy (see image 1; 2) findings were consistent with AIH with moderate activity, grade 3/4, stage 2-3/4 (Scheuer scheme). Pretreatment simplified score was 6 points, suggestive of probable diagnosis of AIH. In the setting of acute HEV infection, patient was not started on corticosteroids and azathioprine. The patient's liver function test trended down significantly in a period of just 2 weeks with clinical improvement. Discussion: It has been postulated that a combination of environmental triggers, failure of immune system tolerance, and a genetic predisposition may induce a T cell-mediated immune attack against the liver. There are several scenarios which could be possible for the current presentation in our case; the presence of severe acute chronic hepatitis may be secondary to AIH decompensated by acute virus infection of HEV vs false positive results of anti-HEV antibodies in patients with chronic liver disease of autoimmune etiology vs low HEV viremia seen in minority of patients with chronic AIH highlighting the possibility of HEV also being a trigger for the trigger for AIH. It is standard practice to test for hepatitis A, B and C in patients with clinical signs of AIH. We also suggest testing for HEV in patients who immigrated or recently travelled to endemic areas. Patients who test positive for IgM should be confirmed with real time PCR technique and/or molecular liver histology and immunohistochemical testing should be performed.Figure 1Figure 2Figure 3