S3164 Successful Use of Ribavirin in an Immunocompetent Patient With Severe Hepatitis E

Abstract

Introduction: Hepatitis E is usually a self-limited disease that does not require antiviral therapy. Limited use of Ribavirin has been described in immunocompromised patients with chronic hepatitis E virus (HEV) infection. We present a rare case of acute hepatitis E in an immunocompetent patient who was successfully treated with Ribavirin, highlighting its potential use in severe cases. Case Description/Methods: A 23-year-old man presented with 5 days of abdominal pain and jaundice 1 month after returning from South Asia. History was negative for liver disease, unprotected sexual activity, or toxic ingestion. Liver chemistries were abnormal with AST 1684, ALT 3001, T bili 6.6, and ALP 188. Initial CBC, BMP, and coagulation studies were at baseline. Abdominal imaging was also unremarkable except for evidence of hepatic parenchymal changes. An extensive viral, toxicological, and autoimmune workup revealed acute HEV infection with a viral load of 1.8 million IU/ml. He was initially managed conservatively but required admission to the liver service by day 4 due to persistently abnormal liver studies and a worsening INR to 1.7. A trial of Ribavirin 200mg BID was initiated and the patient’s transaminases and INR started to downtrend by day 5. By day 6, his symptoms improved and viral load decreased to 23,700 IU/mL. He was discharged on day 8 with a 12-week course of Ribavirin 400mg BID. Liver studies had completely resolved at follow-up 35 days after presentation. Discussion: HEV is a common source of liver failure in regions with high endemicity but is typically self-limited in developed nations. No therapy has been approved for acute hepatitis E, however, ribavirin, a nucleoside inhibitor used for hepatitis C, has been administered effectively in immunocompromised patients with chronic HEV. Limited instances of it being used in healthy patients with acute hepatitis E have also been reported but no clear guidance exists on its use in such rare, severe cases. Although our patient was young and healthy, we chose to trial Ribavirin in light of worsening synthetic liver function and to forestall impending fulminant liver failure. Various regimens have been previously described, ranging from 600-1200mg/day, but we found that a dose of 400-800mg/day was sufficient to induce a 76-fold decrease in viral load within days of Ribavirin initiation. This case provides yet another example of Ribavirin’s effectiveness in the treatment of severe hepatitis E and raises the need for further evaluation for use in such cases.