Unexpected long‐lasting anti‐HEV IgM positivity: Is HEV antigen a better serological marker for hepatitis E infection diagnosis?

Hepatitis E virus (HEV) is the leading cause of acute hepatitis worldwide. The minimum criterion for diagnosis of acute infection is detection of anti‐HEV antibodies, although there are scant data on IgM duration. Our aim was to assess the persistence of HEV markers after acute self‐limited hepatitis E. HEV serological tests (IgM by Mikrogen and Wantai and HEV‐Ag) and HEV RNA were carried out in two cohorts: (a) patients with prior acute hepatitis E (ALT >10 x ULN plus positive IgM ± HEV RNA) currently self‐limited and (b) 50 blood donors with positive HEV RNA. Among 25 cases of prior acute hepatitis E, after a median follow‐up of 34 months, all presented undetectable HEV RNA. However, anti‐HEV IgM remained detectable in 14 (56%) by Mikrogen, 6 (24%) by Wantai and none for HEV‐Ag. Anti‐HEV IgM tested positive in 80%‐100% within the second year and 17%‐42% over 3 years later, by Wantai and Mikrogen, respectively. Among HEV RNA‐positive donors, 12 (25%) tested positive for either IgM by Mikrogen or Wantai, 9 (18%) for both and 18 (36%) for HEV‐Ag. HEV‐Ag positivity was more likely as HEV RNA was higher (14% if <2.2 log IU/mL; 64% if RNA ≥ 3.7). Overall, HEV‐Ag performed best, with a positive predictive value of 100% and diagnostic accuracy of 57%. Anti‐HEV IgM exhibited unexpectedly long persistence after a self‐limited acute hepatitis E. HEV‐Ag had the best performance and could be especially useful in settings where HEV RNA is not available.     

Low prevalence of hepatitis E in Iceland: a seroepidemiological study

Objective: Hepatitis E virus (HEV) infection has been reported to be more prevalent in the developed countries than previously thought. HEV infection is an important differential diagnosis in patients with drug-induced liver injury (DILI). The prevalence of hepatitis E was investigated in the general population of Iceland, among pig farmers and patients with DILI.

Materials and methods: Serum samples were tested for hepatitis E IgG, with two commercial ELISA tests: Diagnostic Bioprobes Srl. (Dia Pro) and the Wantai HEV IgG and subjects repeatedly reactive were tested with an immunoblot assay (RecomLINE). Three groups were tested: (1) healthy volunteers (HV), (2) pig farm workers (PFWs) and (3) patients participating in a nationwide prospective study on DILI.

Results: Overall 291 individuals were tested, HV (n?=?195), PFW (n?=?21) and DILI (n?=?75). Only 6/291 (2.1%) tested positive for IgG antibodies to HEV in all three tests. Three HV were HEV IgG antibody positive and three in the DILI group. One PFW tested positive in the Dia Pro and Wantai tests but not in the immunoblot assay. All but one of the positive individuals in all three tests was either of foreign national origin or had spent extended period of time outside of Iceland.

Conclusions: The seroprevalence of hepatitis E appears to be lower in Iceland than majority of recent studies in other western countries have demonstrated. This may be due to relative isolation and severe restriction on import of livestock from other countries.     

Leptospirosis presenting as acute encephalitis syndrome (AES) in Assam,India

ObjectiveTo establish leptospirosis as a new aetiology of the patients presenting acute encephalitis syndrome (AES).MethodsJapanese encephalitis, West Nile, Dengue and Chikungunya negative samples were tested by IgM capture ELISA for leptospira specific IgM. For further confirmation, the IgM positive samples were subjected to Microscopic agglutination test (MAT). The clinical details and laboratory findings of the positive patients were recorded.ResultsWe report 8 cases of leptospirosis presenting as AES, proven on IgM capture ELISA and confirmed by MAT. Fever (100%) and altered sensorium (62.5%) were two most common symptoms. Low haemoglobin (7.5 ± 2.8) g/dL, elevated blood urea (79.16 ± 46.43) mg/dL, serum creatinine (1.5 ±1.2) mg/dL, SGOT (66.5 ± 14.84) U/L and SGPT (70.5 ± 4.9) U/L were observed in positive patients.ConclusionsThis is the maiden study reporting leptospirosis as a new aetiology of the patients presenting AES. Establishing aetiology is very important for a successful therapy at least in treatable conditions like leptospirosis.     

HEV核酸、抗原、抗体对HEV感染的诊断价值

目的探讨HEV核酸(HEV RNA)、HEV抗原(HEV Ag)、HEV抗体(HEV IgM抗体和HEV IgG抗体)在临床诊断HEV感染中的作用。方法收集在北京大学人民医院进行HEV IgM抗体和HEV IgG抗体检测的13992例标本,其中1924例HEV IgM抗体或HEV IgG抗体阳性。分别采用荧光PCR法进行HEV RNA和基因型检测,酶联免疫吸附试验方法进行HEV Ag、HEV IgM抗体和HEV IgG抗体检测,并检测ALT、AST、TBil和DBil水平。计量资料两组间比较采用Mann-Whitney U检验。结果1924例标本中HEV IgM抗体阳性152例(7.9%),HEV IgG抗体阳性1897例(98.6%),HEV RNA阳性62例(3.2%),HEV Ag阳性55例(2.9%)。HEV IgM抗体阳性组中HEV RNA阳性率为40.8%(62/152),HEV Ag阳性率为36.2%(55/152)。HEV RNA阳性组中HEV Ag阳性率为88.7%(55/62)。HEV RNA阳性组(n=62)ALT、AST、TBil、DBil水平高于HEV RNA阴性组(n=90)(Z值分别为-7.609、-6.942、-5.815、-6.130,P值均<0.001),HEV Ag阳性组(n=55)ALT、AST、TBil、DBil水平明显高于HEV Ag阴性组(n=97)(Z值分别为-6.413、-5.786、-5.199、-5.545,P值均<0.001)。巢式PCR扩增测序结果显示58例HEV RNA阳性,4例阴性。HEV IgG抗体阳性高水平明显降低HEV Ag检测的S/CO值,甚至出现阴性结果。结论与HEV抗体相比,HEV Ag可以提高戊型肝炎的诊断水平,具有一定的临床意义;高水平的转氨酶或胆红素可以辅助诊断HEV感染;高水平的HEV IgG抗体会降低HEV Ag检测值,检测时应注意HEV Ag阴性时HEV IgG抗体值。     

Relevance of chronic hepatitis E in liver transplant recipients: a real‐life setting

The chronic course of hepatitis E virus (HEV) infections in orthotopic liver transplant (OLT) recipients has been described previously, but prospectively collected data are rare. We aimed to study the role of chronic hepatitis E in OLT in a real‐life setting. Therefore, 287 adult OLT recipients (169 male [59%], median age 56 years) were prospectively tested by HEV polymerase chain reaction assay (lower level of detection = 10 IU/mL), irrespective of their level of liver enzymes. In 4 patients (1.4%), chronic HEV infection was diagnosed. All 4 patients were male, and their age (median 48.5 years), the time since transplantation (median 45.5 months), and bilirubin level (median 0.6 mg/dL) did not differ significantly from the total cohort. However, alanine transaminase and aspartame transaminase levels were significantly higher in HEV‐infected patients (75–646 U/L, median 216 U/L and 68–317 U/L, median 108 U/L) than in non‐infected patients (6–617 U/L, median 41 and 6–355 U/L, median 36; P = 0.004 and 0.040, Mann–Whitney test). In 3 patients, liver biopsy was performed and revealed signs of inflammation and chronic liver disease, as enlarged densely infiltrated portal tracts with mild‐to‐moderate interface hepatitis. All infected patients were treated with ribavirin with the starting dose adjusted to renal function (400–800 mg/day). In 2 patients, dose reduction was necessary. Transaminases normalized in all 4 patients, and all patients cleared their infection within 3 months of ribavirin treatment. However, 1 patient experienced viral relapse 12 weeks after discontinuation. Ribavirin medication was re‐started and viral clearance occurred within 8 weeks and persisted. Sequence analysis of the HEV genome of this patient revealed that he was infected with an HEV variant, which recently has been shown to have a reduced response to ribavirin in cell culture. The risk of chronic HEV infections in OLT recipients in low‐endemic countries should not be overestimated. No case of chronic hepatitis E was observed in patients with normal liver enzymes, indicating that general screening of all OLT recipients is not necessary. However, if chronic hepatitis E develops, it can be treated efficiently with ribavirin.     

Hepatitis e virus infection in fulminant hepatitis patients and an apparently healthy population in Bangladesh

This is the first study comparing hepatitis E virus (HEV) infection in Bangladesh in fulminant hepatitis (FH) patients presumed to have a viral cause and in the apparently healthy population. Sera from 22 FH patients were analyzed for antibodies to hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C and D viruses, and HEV and for hepatitis B surface antigen (HBsAg). Anti-HEV immunoglobulin M (IgM) was detected in the sera of 63.6% of patients, whereas 35.7% were positive for HBsAg. A high prevalence of HEV infection (83.3%) was noted in the HBV carriers. Serum samples from 273 apparently healthy individuals were tested for antibodies to HAV and HEV. Anti-HEV IgM was detected in 7.3% of the samples. The seroprevalence of HAV differed from that of HEV in the same population because all samples were negative for anti-HAV IgM. These data indicate that HEV infection is highly endemic in Bangladesh.     

Investigation of an epidemic of Hepatitis E in Nellore in south India

Objective To determine the incidence of acute hepatitis because of hepatitis E virus (HEV) and the source of the epidemic in Nellore in south India in 2008. Methods Anti‐HEV IgM ELISA and RT‐PCR for HEV‐RNA were carried out on blood and stool samples from patients with acute hepatitis presenting to different hospitals in the city. The city was divided into 33 clusters, and 20 families from each cluster were systematically interviewed to determine the incidence of hepatitis E in the city. The survey was conducted on 2685 residents of 673 households from 24th November to 4th December 2008. Results The overall incidence of hepatitis was 5.7% (152/2685), i.e. an estimated 23 915 persons in the city were affected. There were two deaths because of acute hepatitis in the population surveyed translating to an estimated 315 deaths. Men had higher attack rates than women (7.8%vs. 3.5%) and young adults compared to children under 5 years (6.9%vs. 2.9%). Families drinking water from the pumping station at Bujjamarevu had the highest attack rate of 54.5% (39.8–69.2%). HEV IgM antibodies were present in 80/100 plasma samples tested. HEV‐RNA was detected in 43/100 individuals tested, and isolates were characterized as genotype 1 by sequencing. Conclusion Sewage draining into the river close to the pumping stations and broken pipelines crossing sewage drains may have triggered this large outbreak.     

Temporal profile of HEV RNA concentration in blood and stool from patients with acute uncomplicated hepatitis E in a region with genotype 1 predominance

Acute hepatitis E virus (HEV) is associated with viremia and faecal excretion of the virus. The information on duration and temporal pattern of viremia and faecal shedding in HEV infection is important, but is not available. Serial serum and stool specimens were collected from patients with acute hepatitis E (typical clinical picture, serum alanine aminotransferase levels > 5‐folds the upper limit of normal and presence of IgM anti‐HEV), beginning from within 7 days of the onset of symptoms. HEV RNA concentrations were measured in sera and 10% stool suspensions, using a real‐time Taqman‐based nucleic acid amplification assay. Seventeen patients (median age 25 [range 19‐61] years; all men) were enrolled within a median of 5 (range 3‐8) days of the onset of the first symptom and provided 113 serum specimens and 71 stool specimens. The median (range) highest levels of serum bilirubin, alanine aminotransferase and aspartate aminotransferase in the patients were 10.3 (5.9‐43.4) mg/dL, 1817 (442‐4642) IU/L and 1016 (88‐4561) IU/L, respectively. All the 17 patients had demonstrable viremia, and 12 of the 13 patients who were tested had faecal excretion at one or more time points. The HEV RNA titres were the highest in the early phase of disease and declined rapidly with time, becoming nondetectable in the serum by day 20 and in the stool by day 21. In most of the patients with acute uncomplicated acute hepatitis E, the degree of viremia and faecal shedding decline quickly after the onset of clinical illness and rapidly disappear in parallel with each other.     

Superimposed acute hepatitis E infection in patients with chronic liver disease.

BACKGROUND: The natural history of infection with hepatitis E virus (HEV) in patients with chronic liver disease (CLD) is not well described. Our study aims to document the presentation, course and outcome of HEV superinfection in patients with CLD. METHODS: Over an 18-month period, ten patients with CLD were diagnosed to have HEV superinfection by detection of anti-HEV IgM antibodies in a setting of acute worsening. These patients were tested for HBsAg, IgM anti-HBc, anti-hepatitis C virus antibodies and IgM anti-hepatitis A virus antibodies, and were followed-up. RESULTS: The etiology of underlying CLD in the 10 patients (9 men; mean [SD] age 42.4 [10.3] years) was alcohol in five patients, hepatitis B in two, hepatitis C in one and cryptogenic in two. Seven patients presented for the first time with recent-onset liver decompensation (median duration 27 days, range 7-45). All 10 had ascites and 7 had hepatic encephalopathy. Four patients developed renal failure during the course of illness. The median (range) bilirubin, ALT and albumin levels at presentation were 18.6 (4.9-32.6) mg/dL, 105 (28-6610) IU/L and 32 (29-41) g/L, respectively. At 8 weeks, only one patient had normalization of serum bilirubin or ALT levels. Three patients (30%) died, including two of renal failure and one of massive upper GI bleed. CONCLUSIONS: Superinfection with HEV in patients with CLD causes severe liver decompensation, which is frequently complicated with hepatic encephalopathy and renal failure. Acute hepatitis E in these patients has a protracted course with high morbidity and mortality.     

Epidemic hepatitis E: serological evidence for lack of intrafamilial spread.

INTRODUCTION: Hepatitis E presents as epidemic as well as sporadic disease. Fecal contamination of drinking water results in epidemics of hepatitis E. The extent of intrafamilial spread needs to be assessed employing serological assays. AIMS: To understand the dynamics of intrafamilial spread of the disease. METHODS: The study was conducted using blood samples collected during the 1988 and 1989 epidemics of viral hepatitis in Kudal and Atit villages of Maharashtra state; the epidemics were subsequently shown to be due to hepatitis E virus (HEV). The one-time collection carried out at the end of the Kudal epidemic was from 184 apparently healthy individuals irrespective of family history of jaundice during the epidemic. In the Atit epidemic, 153 family contacts of 49 IgM anti-HEV positive patients were bled. An additional 151 blood samples were collected from apparently healthy individuals irrespective of family history of jaundice during the epidemic. One month later, blood samples were collected from 64 of the 153 family contacts. Relevant history was recorded each time. All serum samples were tested for ALT levels and for IgM and IgG antibodies to hepatitis E virus employing ELISA. RESULTS: IgM anti-HEV positivity among persons with family history of jaundice was not different from those without such a history (8/62 [12.9%] and 11/122 [9%] at Kudal; 9/57 [15.8%] and 22/94 [23.4%] at Atit; p > 0.1). Excluding IgG anti-HEV positive samples from the analysis also yielded non-significant results. Of the 32 follow-up samples collected from family contacts without IgG or IgM antibodies to HEV in the initial blood sample, 31 remained IgM and IgG anti-HEV negative at the end of 1 month. One of the family contacts was found to be IgG anti-HEV positive in the second blood sample. The disease was not related to the index case. CONCLUSION: Intrafamilial spread of HEV is negligible.     

Spectrum of viral hepatitis in thalassemic children receiving multiple blood transfusions.

AIM: To investigate the prevalence of infection with hepatitis viruses in children with thalassemia receiving multiple blood transfusions. METHODS: Sera from 50 children with thalassemia aged 5-15 years (30 boys), who had each received over 80 units of blood, were evaluated for the presence of markers for hepatitis A virus (HAV; IgG and IgM anti-HAV), hepatitis B virus (HBV; HBsAg, and IgG and IgM anti-HBc), hepatitis C virus (HCV; IgG and IgM anti-HCV, and HCV RNA) and hepatitis E virus (HEV; IgG and IgM anti-HEV). IgM anti-hepatitis D virus (HDV) was looked for only in HBsAg or IgM anti-HBc positive sera. RESULTS: No child had evidence of recent HAV or HDV infection. IgG anti-HAV was positive in 12 children. One patient had acute HBV infection. Nine patients were HBsAg-positive. HCV infection was present in 15 cases; six of them were HCV RNA positive, and three had superinfection with hepatitis B. Recent HEV infection was present in 5 cases. CONCLUSION: Thalassemic patients receiving multiple blood transfusions often acquire hepatitis B (20%) and C (30%) infections. Recent hepatitis E infection was documented in 10% in this one-point study.     

Diagnostic Performance of an Automated System for Assaying Anti-Hepatitis E Virus Immunoglobulins M and G Compared with a Conventional Microplate Assay

To evaluate the diagnostic performance of the Liaison^® Murex anti-HEV IgM and IgG assays running on the Liaison^® instrument and compare the results with those obtained with Wantai HEV assays. We tested samples collected in immunocompetent and immunocompromised patients during the acute (HEV RNA positive, anti-HEV IgM positive) and the post-viremic phase (HEV RNA negative, anti-HEV IgM positive) of infections. The specificity was assessed by testing HEV RNA negative/anti-HEV IgG-IgM negative samples. The clinical sensitivity of the Liaison^® IgM assay was 100% for acute-phase samples (56/56) and 57.4% (27/47) for post-viremic samples from immunocompetent patients. It was 93.8% (30/32) for acute-phase (viremic) samples and 71%% (22/31) for post-viremic samples from immunocompromised patients. The clinical sensitivity of the Liaison^® IgG assay was 100% for viremic samples (56/56) and 94.6% (43/47) for post-viremic samples from immunocompetent patients. It was 84.3% (27/32) for viremic samples and 93.5% (29/31) for post-viremic samples from immunocompromised patients. Specificity was very high (>99%) in both populations. We checked the limit of detection stated for the Liaison^® IgG assay (0.3 U/mL). The clinical performance of the Liaison^® ANTI-HEV assays was good. These rapid, automated assays for detecting anti-HEV antibodies will greatly enhance the arsenal for diagnosing HEV infections.     

Hepatitis E Virus Genotype 1 Cases Imported to Portugal from India, 2016

Hepatitis E in industrialized countries is mainly associated with genotype 3 hepatitis E virus (HEV) and normally causes a sporadic self-limiting disease in immunocompetent individuals. Unlike genotype 3, genotypes 1 and 2 circulate in developing countries, produce severe disease and occur in the epidemic form. Hepatitis E occurring in travellers returning from endemic areas in developing countries is not a novel epidemiological occurrence, however the vast majority of cases remain to be genetically studied. The present study describes two cases of severe acute hepatitis E that required hospitalization for 6 and 9 days in two individuals of Indian nationality that had recently migrated to Portugal to work. The retrieved HEV sequences both belonged to genotype 1 and had a high degree of nucleotide sequence identity, clustering with strains isolated in India and Nepal, in 2013 and 2014. Confirmed HEV genotypes of increased pathogenicity like genotype 1 are being introduced into otherwise naïve populations of industrialized countries such as European countries with consequences difficult to predict. As far as we know the present study is the first in Portugal to describe and genetically characterize imported cases of hepatitis E infection caused by HEV genotype 1.     

Serological and molecular study of Hepatitis E virus in pediatric patients in Mexico

Introduction and objectivesCases of viral hepatitis reported in Mexico are typically identified as hepatitis A, B and C. However, unspecified cases are reported annually. Hepatitis E virus (HEV) is an emergent agent that causes a self-limiting infection that can evolve to chronic in immunosuppressed individuals. In Mexico, HEV genotype 2 is considered endemic, though it's the prevalence is not well known. Therefore, the present study was designed to determine the prevalence of HEV among patients at the “Hospital Infantil de Mexico Federico Gomez”.Materials and methodsThe study included 99 patients, anti-HEV antibody (IgG and IgM) were detected by indirect ELISA and viral genome was identified using RT-PCR technique. Two PCR products of positive cases were sequenced.ResultsELISA results were positive in 3% and 6%, for IgG and IgM respectively, 54.5% prevalence was found by PCR. Low lymphocyte count (p < 0.05) and malnutrition (p < 0.005) were significant factors for high PCR prevalence and could increase the possibility of infection. Two samples were sequenced and confirmed the presence of HEV genotype 3.ConclusionsThis report reveals the incidence of HEV in pediatric patients in Mexico. Moreover, the identification of HEV genotype 3 in human samples suggests a potential zoonotic risk that requires further research.     

An outbreak of hepatitis E in an urban area of Bangladesh

We investigated an outbreak of jaundice in urban Bangladesh in 2010 to examine the cause and risk factors and assess the diagnostic utility of commercial assays. We classified municipal residents reporting jaundice during the preceding 4 weeks as probable hepatitis E cases and their neighbours without jaundice in the previous 6 months as probable controls. We tested the sera collected from probable cases and probable controls for IgM anti‐hepatitis E virus (HEV), and the IgM‐negative sera for IgG anti‐HEV using a commercial assay locally. We retested the IgM‐positive sera for both IgM and IgG anti‐HEV using another assay at the Centre for Disease Control and Prevention (CDC), USA. Probable cases positive for IgM anti‐HEV were confirmed cases; probable controls negative for both IgM and IgG anti‐HEV were confirmed controls. We explored the local water supply and sanitation infrastructure and tested for bacterial concentration of water samples. Probable cases were more likely than probable controls to drink tap water (adjusted odds ratio: 3.4; 95% CI: 1.2–9.2). Fifty‐eight percentage (36/62) of the case sera were IgM anti‐HEV positive; and 75% of the IgM‐positive samples were confirmed positive on retesting with another assay at CDC. Compared to confirmed controls, cases confirmed using either or both assays also identified drinking tap water as the risk factor. Two tap water samples had detectable thermotolerant coliforms. Research exploring decentralized water treatment technologies for sustainable safe water might prevent HEV transmission in resource‐poor cities. Detection of serological markers in a majority of probable cases implied that available diagnostic assays could adequately identify HEV infection during outbreaks.     

抗戊型肝炎病毒E2 IgM诊断急性戊型肝炎的敏感性和特异性

目的评价抗戊型肝炎病毒（HEV）衣壳蛋白重组抗原E2 IgM（抗-E2 IgM）诊断急性散发性戊型肝炎的敏感性和特异性。方法用酶联免疫吸附法检测176份急性散发性戊型肝炎和191份急性散发性非甲～非戊型肝炎患者血清中抗-E2 IgM，与国产传统试剂和新加坡Genelabs试剂检测的IgM（GL—IgM）作比较；对抗-E2 IgM阳性血清检测血清中HEV RNA，采用logistic回归分析检测抗-E2 IgM和HEV RNA的相关因素。结果在176份急性戊型肝炎患者血清中，抗-E2 IgM的检出率为68．75％，国产传统试剂抗-HEV IgM检出率为56．25％，x^2IgM=6．49，P〈0．05。在191份急性非甲～非戊型肝炎血清中有37例（19．37％）抗-E2 IgM阳性，其中11例GL—IgM同时阳性；在158份抗-E2 IgM阳性血清中，有81例HEV RNA阳性（51．27％），其中急性戊型肝炎的阳性率为57．02％，急性非甲～非戊型肝炎的阳性率为32．43％，23例抗-E2 IgM阴性的急性戊型肝炎患者的血清，无一例检测到HEV RNA。Logistic多因素回归分析发现，抗-E2 IgM的检出率与发病至人院时间、年龄、血清胆红素、血清氨基转移酶水平无关，血清丙氨酸氨基转移酶水平与HEV RNA水平呈正相关（P=0．024）。结论抗-E2 IgM是HEV急性期感染敏感性和特异性强的血清学指标；HEV感染仍是部分临床诊断为急性非甲～非戊型肝炎的病因；持续HEV病毒血症可能是影响急性戊型肝炎病情的重要因素。     

Hepatitis E in Damascus, Syria

Summary A hospital-based study of acute hepatitis was conducted in Damascus, Syria, from 1995 to 1998. One hundred ninety-three sera from defined acute hepatitis cases were screened by ELISA for IgM anti-HAV, HBsAg, IgM anti-HBc and anti-HCV. Serum samples negative for all markers indicating recent infection by hepatitis A, B, or C were tested for HEV markers. Overall, 47 cases (24.4%) had no detectable hepatitis markers (non-A-E). HAV infection was detected in 71.2% of all viral hepatitis cases. Acute hepatitis B and C constituted 24 and 1.4% of the cases, respectively. Only five cases of acute hepatitis E were noted. Of 47 patients who had non-A-E hepatitis, fifteen (31.9%) tested positive for IgG anti HEV. This study provides indirect evidence that HEV is very likely to be endemic in Damascus, Syria. It reports for the first time the occurrence of hepatitis E in the country, a health problem that should be investigated further.     

Case of domestically infected hepatitis E with marked thrombocytopenia]

A 52-year-old man was admitted to our hospital for fever, jaundice, and general malaise. Laboratory data revealed elevated serum liver enzyme levels (AST 2377IU/L, ALT 2756IU/L) and bilirubin (T-Bil 3.7 mg/dl). Blood count showed a marked decrease of platelets (2.0 x 10(4)/microl). Serological and virological analysis showed positive results for HEV IgM and HEV RNA, indicating a diagnosis of acute hepatitis E. The serum ferritin level was also markedly elevated (23200 ng/ml). A diagnosis of virus associated hemophagocytic syndrome (VAHS) was strongly suggested. This is the first report of hepatitis E most likely accompanied by VAHS.