The Forgotten Hepatitis: Two Cases of Hepatitis E in Patients Returning from Operation Iraqi Freedom

Abstract

Purpose: Hepatitis E is a single-stranded RNA virus that causes enterically transmitted acute viral hepatitis. It is the second leading cause of sporadic hepatitis in North Africa and the Middle East. Although relatively rare in the United States, this viral hepatitis is of more concern today given US involvement in Iraq and Afghanistan and the ease of world travel. While it is typically a self-limited illness, it can cause fulminant hepatitis. Our first case is a 54 year-old male contractor with history of chronic hepatitis B who had been working in Iraq for several years. He had achieved sustained viral response with lamivudine since the late 1990s. In May 2008, he developed right upper quadrant pain, increasing abdominal girth, and scleral icterus. Labs revealed hepatitis B virus DNA of 31 million copies and elevated transaminases (AST 1373, ALT 665, alkaline phosphatase 233, total bilirubin 29.4). He was also found to have positive hepatitis E IgM. Given his presentation and available laboratory data, we cannot determine if the acute hepatitis E infection caused the reactivation of his chronic hepatitis B infection or if it was an incidental finding. He was treated supportively and switched to entecavir for treatment of his hepatitis B infection with good viral and symptomatic response. Our second case is a 28 year-old active duty female who had been deployed in Iraq for 12 months when she developed nausea and vomiting. She was first given promethazine and hydration, but she presented two days later with worsening symptoms and jaundice. She was then found to have elevated transaminases (AST 1501, ALT 1541, alkaline phosphatase 145, total bilirubin 8.0). Acute viral hepatitis work-up was significant for positive hepatitis E IgM. She progressed to fulminant hepatic failure and had to be medically evacuated to the US. She ultimately received a cadaveric liver transplant and has done well postoperatively. Although common in Southeast Asia, North Africa, and the Middle East, hepatitis E is not prevalent and not routinely checked on acute hepatitis panels in the U.S. It is an opportunistic infection that is spread via fecal-oral route, so improving sanitation and water purification techniques is tantamount for preventing spread in endemic areas. While it is usually a self-limited illness, it has been associated with fulminant hepatic failure as illustrated in one of our patients. A vaccine against hepatitis E is currently in development, but is not yet commercially available. With our military and civilian presence in the Middle East and other endemic areas, hepatitis E should be thought of and screened for in patients presenting with acute hepatitis who have recently been to relevant areas.