Hepatitis E is endemic in many developing countries where it causes substantial morbidity. In industrialised countries, it is considered rare, and largely confined to travellers returning from endemic areas. However, there is now a growing body of evidence that challenges this notion. Autochthonous hepatitis E in developed countries is far more common than previously recognised, and might be more common than hepatitis A. Hepatitis E has a predilection for older men in whom it causes substantial morbidity and mortality. The disease has a poor prognosis in the context of pre-existing chronic liver disease, and is frequently misdiagnosed as drug-induced liver injury. The source and route of infection remain uncertain, but it might be a porcine zoonosis. Patients with unexplained hepatitis should be tested for hepatitis E, whatever their age or travel history.

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(08)70255-X.pdf

Hepatitis E: an emerging infection in developed countries

Hepatitis E virus (HEV) infection is a worldwide disease. An improved understanding of the natural history of HEV infection has been achieved within the last decade. Several reservoirs and transmission modes have been identified. Hepatitis E is an underdiagnosed disease, in part due to the use of serological assays with low sensitivity. However, diagnostic tools, including nucleic acid-based tests, have been improved. The epidemiology and clinical features of hepatitis E differ between developing and developed countries. HEV infection is usually an acute self-limiting disease, but in developed countries it causes chronic infection with rapidly progressive cirrhosis in organ transplant recipients, patients with hematological malignancy requiring chemotherapy, and individuals with HIV. HEV also causes extrahepatic manifestations, including a number of neurological syndromes and renal injury. Acute infection usually requires no treatment, but chronic infection should be treated by reducing immunosuppression in transplant patients and/or the use of antiviral therapy. In this comprehensive review, we summarize the current knowledge about the virus itself, as well as the epidemiology, diagnostics, natural history, and management of HEV infection in developing and developed countries.

Hepatitis E Virus Infection

Hepatitis E virus (HEV) infection can lead to acute and chronic hepatitis as well as to extrahepatic manifestations such as neurological and renal disease; it is the most common cause of acute viral hepatitis worldwide. Four genotypes are responsible for most infection in humans, of which HEV genotypes 1 and 2 are obligate human pathogens and HEV genotypes 3 and 4 are mostly zoonotic. Until quite recently, HEV was considered to be mainly responsible for epidemics of acute hepatitis in developing regions owing to contamination of drinking water supplies with human faeces. However, HEV is increasingly being recognized as endemic in some developed regions. In this setting, infections occur through zoonotic transmission or contaminated blood products and can cause chronic hepatitis in immunocompromised individuals. HEV infections can be diagnosed by measuring anti-HEV antibodies, HEV RNA or viral capsid antigen in blood or stool. Although an effective HEV vaccine exists, it is only licensed for use in China. Acute hepatitis E is usually self-limiting and does not require specific treatment. Management of immunocompromised individuals involves lowering the dose of immunosuppressive drugs and/or treatment with the antiviral agent ribavirin.

Hepatitis E virus infection.

https://www.gastrojournal.org/article/S0016-5085(11)01151-6/pdf

Acute Hepatitis E Infection Accounts for Some Cases of Suspected Drug-Induced Liver Injury

In developed countries, the incidence of hepatitis E virus (HEV) infection and the resulting seroprevalence are uncertain. Published estimates of seroprevalnce in these populations range from 0.26% to 31%, which may in part reflect the variety of assays used by different studies. This study compared the performance of two commercial assays (Genelabs [Singapore] and Wantai 'Beijing, China' HEV IgG EIA kits) and reviewed published estimates of anti-HEV seroprevalence in developed countries. The assays were compared using the WHO anti-HEV reference serum, sera from UK-acquired cases of genotype 3 HEV infections and 500 UK blood donor sera. The PE2 assay was found to be more sensitive than the GL assay (lower limit of detection for HEV IgG 0.25 vs. 2.5 WHO units/ml); it was positive in more sera from proven cases (98% vs. 56%), remained positive for longer post infection and resulted in a substantially higher estimate of seroprevalence in blood donors (16.2% vs. 3.6%). these results suggest that published studies of HEV seroprevalence using the GL assay have underestimated the true figure and that a properly validated method is required to make meaningful comparisons of HEV seroprevalence between populations.

A comparison of two commercially available anti-HEV IgG kits and a re-evaluation of anti-HEV IgG seroprevalence data in developed countries

Background and Aim:  Locally acquired hepatitis E virus (HEV) infection has been described in a number of developed countries and is thought to be zoonotic from pigs. Little is known about hepatitis E in humans in New Zealand (NZ) but 90% of NZ pigs show evidence of HEV infection. The aim of this study was to investigate the epidemiology of hepatitis E infection in NZ by documenting HEV immunoglobulin (Ig) G seroprevalence in NZ blood donors, testing patients with unexplained hepatitis for HEV, and comparing genetic sequences of human HEV with local porcine isolates.



Methods:  In total, 265 blood donors were tested for HEV IgG and 77 patients with unexplained hepatitis were tested for HEV. Viral sequences were compared with known HEV isolates including those from NZ pigs.



Results:  The HEV IgG seroprevalence was 4%. HEV genotype 3 was isolated in four patients with unexplained hepatitis. Clinical and sequencing data suggest that two cases were acquired in Europe and two in NZ. All cases were in elderly patients, one of whom was asymptomatic and initially misdiagnosed as a drug reaction. The NZ-acquired cases were most similar to HEV from Japan, and bore little sequence homology to HEV isolated from NZ pigs.



Conclusions:  Hepatitis E does occur in NZ in patients who have not traveled to endemic areas and seems to affect the elderly. The seroprevalence data suggest that subclinical/unrecognized infection is common. Sequencing data suggest that some reservoir other than pigs could be the source of HEV in NZ. It is recommend that all patients with unexplained hepatitis, whatever their age or travel history, are tested for HEV.

Hepatitis E in new zealand.

BackgroundThe Glasgow Blatchford Score (GBS) is a validated risk assessment tool in primary upper gastrointestinal haemorrhage, which accurately predicts the need for intervention (endoscopic therapy, blood transfusion or surgery) or death.AimsTo identify the GBS that predicts lack of intervention o

Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score.

A 52 year old man was referred to the jaundice hotline clinic by his general practitioner with symptoms of malaise and lethargy over one year and a seven day history of jaundice. Apart from a laparoscopic cholecystectomy eight years earlier, he had no other relevant medical history and took no drugs. On examination, he was jaundiced but had no other abnormal physical signs.

His laboratory findings were: bilirubin 135 µmol/l (normal range 3-17), alkaline phosphatase 971 U/l (3-110), alanine aminotransferase 154 U/l (3-35), albumin 35 g/l (35-45).

Ultrasound of the liver showed coarse echotexture and no intrahepatic biliary duct dilatation. Views of the common bile duct were poor owing to overlying bowel gas.

The patient went on to have endoscopic retrograde cholangiopancreatography as an outpatient (fig 1⇓).



Fig 1 Results of endoscopic retrograde cholangiopancreatography 





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#### 1 Diagnosis

Endoscopic retrograde cholangiopancreatography showed beading and ectasia (fig 2⇓; small arrows) as a result of multifocal stricturing and dilatation of …

Helen J Fellows

Papers

Hepatitis E in new zealand.

Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score.

Jaundice and malaise in a middle aged man.