Is Acute Hepatitis E Virus (HEV) Infection a Steroid-Responsive Disease?

Abstract

Introduction: While HEV infection often is self-limited, prolonged infection can put the patient at significant risk for liver injury, and treatment with Ribavirin can have mixed success. The following case represents an occasion in which lab result delay and clinical decision-making led to the improved outcome of a patient with acute HEV infection. Case Report: A 50 Year old South Asian female presented to her primary care physician (PCP) with complaints of diarrhea and fever after returning from a recent trip to Pakistan. This was treated by her PCP with Rifaximin, but the diarrhea continued. Lab results showed ALT and AST levels at 985 and 679, respectively. The patient was started on a course of ciprofloxacin and azithromycin, but her condition did not significantly improve. She was then referred to the hepatology clinic for workup. Labs were repeated, and tests for Hepatitis E and autoantibody titers were ordered. The patient followed up two days later and lab results showed elevated immunoglobulin G levels and a positive anti-Smith autoantibody titer (1:80). Autoimmune hepatitis was suspected and a liver biopsy was ordered. The liver biopsy results showed signs of nonspecific lobular inflammatory infiltration, and an order for Prednisone 60 mg by mouth once daily was added to the management plan while awaiting results of other serologies. The patient was then hospitalized for exacerbation of her condition and arthralgia in her extremities. However, she quickly responded to the course of steroids with marked improvement of her liver enzymes. Upon her next follow-up, steroids were being tapered, and the previously ordered pending lab results had come back positive for HEV IgG and IgM. HEV viral load was 145,000 IU/mL, and her ALT and AST had dropped to 164 and 25, respectively. She was started on Ribavirin 600mg daily as per HEV protocol. Within 2 weeks, viral HEV RNA was undetectable and her liver enzymes returned to within normal limits. Discussion: This patient had undiagnosed Hepatitis E, most likely contracted on a recent trip abroad. The inadvertent use of and response to prednisone suggests that steroids may be an efficacious adjunct to ribavirin in the management of acute Hepatitis E.