Hepatitis E in decompensated alcoholic cirrhosis.

Abstract

In a study on a sample of 681 adults from the US acute liver failure (ALF) cohort, Fontana et al. reported that acute hepatitis E virus (HEV) infection was a very rare etiology of ALF, contrasting with previous findings from highly endemic countries. Only 3 patients obtained positive anti-HEV immunoglobulin M (IgM) tests, whereas their HEV RNA tests were negative.1 In the setting of chronic liver disease (CLD), several studies have shown the presence of HEV infection in 3.2%-6.5% cases of decompensated CLD, mostly in patients with alcoholic CLD.2 No differences were observed in terms of mortality between patients with and without HEV infection, but the number of HEV cases was low. To further investigate the impact of HEV in this setting, we conducted a prospective multicenter study on a French cohort of decompensated alcoholic CLD. In line with the data by Fontana et al. in ALF, HEV infection was not found to contribute significantly to hepatic decompensation: among 181 consecutive patients tested for HEV immunoglobulin G (IgG), IgM, and HEV RNA at admission, only 3 had weakly reactive IgM and none had detectable HEV RNA, which suggests that HEV did not contribute to the current decompensation episode. In addition, around 60% of patients had a previous history of decompensation, with an HEV seroprevalence similar to those for whom it was the first episode (34 versus 32%, P = 0.78), which further suggests no relationship between HEV infection and alcoholic CLD decompensation. Globally, aminotransferase levels were only slightly elevated, with mean initial ALT and AST levels of 49 ± 54 IU/L and 112 ± 105 IU/L; this is a point worth noting because previous authors have observed higher ALT levels in patients with HEV infection. Finally, HEV seroprevalence was 33%, with no significant association with demographic or clinical characteristics, including outcome, as shown in Table 1. HEV IgG-Negative (n = 121) HEV IgG-Positive (n = 60) All in all, these data indicate that unsuspected acute HEV infection is not a common occurrence in American and European patients with acute or acute-on-chronic liver failure. However, HEV seroprevalence is high, indicating frequent infection, although asymptomatic in most cases. Fortuitous detection of HEV is therefore likely to occur during an episode of ALF or acute-on-chronic liver failure mainly due to another cause, especially in regions with a high seroprevalence such as southwestern France. HEV testing should be performed more systematically, especially in patients with high ALT levels; and further studies including larger numbers of HEV cases will have to be performed in order to determine the real impact of HEV on ALF patients' outcome. Christophe Renou, M.D.1 Bruno Lesgourgues, M.D.2 Gilles Macaigne, M.D.3 Arnaud Pauwels, M.D.4 Yann Le Bricquir, M.D.5 Jean Henrion, M.D.6 Faiza Khemissa, M.D.7 Emma Clair, M.D.2 Thierry Paupard, M.D.8 Agnes Pelaquier, M.D.9 Hélène Agostini, M.D., Ph.D.10 Anne-Marie Roque-Afonso, M.D., Ph.D.11 1Hepatogastroenterology Unit, Centre Hospitalier Hyères Hyères, France 2Hepatogastroenterology Unit, Centre Hospitalier Montfermeil Montfermeil, France 3Hepatogastroenterology Unit, Centre Hospitalier Marne la Vallée Marne la Vallée, France 4Hepatogastroenterology Unit, Centre Hospitalier Gonesse Gonesse, France 5Hepatogastroenterology Unit, Centre Hospitalier Béziers Béziers, France 6Hepatogastroenterology Unit, Hôpital de Jolimont Jolimont, Belgium 7Hepatogastroenterology Unit, Centre Hospitalier Perpignan Perpignan, France 8Hepatogastroenterology Unit, Centre Hospitalier Dunkerque Dunkerque, France 9Hepatogastroenterology Unit, Centre Hospitalier Montélimar Montélimar, France 10Department of Statistics Hôpital Bicêtre Le Kremlin Bicêtre, France 11Department of Virology Hôpital Paul Brousse Villejuif, France