HEPATITIS E AS A POSSIBLE CONTRIBUTOR TO INTRACRANIAL HEMORRHAGE

Abstract

SESSION TITLE: Critical Care 6 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Hepatitis E has been previously been associated with idiopathic neurological dysfunction, as new information is being reported about the extrahepatic effects. Zhou et al. have found HEV in the CSF of patients with both acute and chronic infections. Shi et al. have also described positive and negative strand HEV RNA in the brain and spinal cord for up to 28 days post-infection. New reports are appearing constantly about the effects of HEV infections. Here we present a case of HEV possibly contributing to intracranial hemorrhage. CASE PRESENTATION: Our patient is 29-year-old female, 25 weeks pregnant by US, who was previously healthy except for a history of two first trimester spontaneous abortions. She was a native of Mexico, living in the United States for six years, with no recent travel or sick contacts. Patient presented with right-sided numbness, headache, and altered mental status. In the ED, CT head noted large intraparenchymal hemorrhage in the left parietal lobe with herniation. She had emergent decompressive craniotomy and was started on levetiracetam for seizure prophylaxis.CTA head, MRV, and cerebral angiogram found no evidence of AV malformation, venous sinus thrombosis, or occlusion. On day five she developed transaminitis, ALT 88 and AST 100, which were previously normal, and Levetiracetam was held out of concerns for drug-induced liver injury. ALT peaked at 503 and AST 289 by day 10. GGT was 13, total bilirubin 1.5, and alkaline phosphatase 116. Labs were negative for Hepatitis A, B, and C. Doppler of the liver showed normal hepatic anatomy, and negative for Budd-Chiari or SVC thrombus. Labs showed normal serum ceruloplasmin, negative Anti-SMA, and negative AMA, iron studies within normal limits. Alpha-1-antitrypsin was mildly elevated. She had no signs of HELLP syndrome. Patient was positive for Hepatitis E IgM, but IgG negative by immunologic studies. Hep E PCR RNA was found to be <1,300 IU/ml. Levetiracetam was resumed on day 15 due to partial seizure. LP was not performed due to concern for hemorrhage. Without specific treatment, her AST/ALT started decreasing by day 20. She continued to have right hemiparesis and hypoesthesia, but was discharged home with physical therapy. DISCUSSION: Our patient had extensive work up for spontaneous hemorrhage, but no specific cause was ever identified. While a limited number of cases report HEV as a cause of coagulopathy, hypercoagulable studies were essentially within normal limits for a pregnant woman; angiography failed to visualize any vascular deformity. CONCLUSIONS: We hypothesize that HEV contributed to her ICH due to HEV’s neurotropic tendencies. Reference #1: Zhou et. al, “Hepatitis E Virus Infects Neurons and Brains”, JID 2017:215, 1197 -1206. Reference #2: Cencic A, Chingwaru W. Hepatitis E Virus (HEV) – An Emerging Viral Pathogen: Springer Netherlands 2010. Reference #3: Shi et. al, “Evidence of Hepatitis E virus breaking the blood brain barrier and replicating in the central nervous system” Journal of Viral Hepatitis, 2016: 23, 930–939. DISCLOSURES: My spouse/partner as a Speaker/Speaker's Bureau relationship with Salix Please note: $1001 - $5000 Added 03/02/2018 by Ebtesam Islam, source=Web Response, value=Consulting fee No relevant relationships by Ximena Solis, source=Web Response