ABSTRACT
Hepatitis E virus genotype 3 infections are normally asymptomatic in immunocompetent individuals. Symptomatic cases of acute icteric hepatitis E are seldom observed among women, younger men and children but are particularly seen in middle-aged/elderly men. We report a case of severe acute hepatitis E caused by genotype 3 in an immunocompetent 40-year-old woman that required prolonged hospitalization. Her medical history included an autoimmune background, namely atrophic gastritis and Graves' disease. She presented an extensive hepatic necrosis as revealed by the high levels of aminotransferases (ALT 4893 U/L; AST 3138 U/L). She showed also a coagulation disorder (prothrombin time; INR = 1.33). Serological markers for hepatitis viruses A, B and C were negative but serum was positive for hepatitis E virus RNA. Sequencing and phylogenetic analysis revealed that the hepatitis E virus strain belonged to subgenotype 3a. This is suggestive of an association between the severe acute hepatitis E virus genotype 3 infection and the autoimmune background.
As infeções pelo vírus da hepatite E do genótipo 3 são normalmente assintomáticas em indivíduos imunocompetentes. Os casos sintomáticos de hepatite E aguda ictérica são raramente observados em mulheres, crianças e jovens adultos, sendo mais frequentes em homens de meia-idade e idosos. Descrevemos um caso de hepatite aguda severa com hospitalização prolongada numa mulher imunocompetente de 40 anos causada pelo vírus da hepatite E do genótipo 3. Da sua história clínica destacavam-se doenças autoimunes, nomeadamente gastrite atrófica e doença de Graves. A mulher apresentava uma necrose hepática grave, revelada pelos altos níveis de aminotransferases (ALT 4893 U/L; AST 3138 U/L), e distúrbios de coagulação (tempo de protrombina; INR = 1,33). Os marcadores serológicos para os vírus das hepatites A, B e C foram negativos; a pesquisa de ARN do vírus da hepatite E foi positiva no soro. A sequenciação e a análise filogenética revelaram que o vírus da hepatite E em causa pertencia ao subgenótipo 3a. Os autores sugerem uma associação entre a infeção aguda severa causada pelo vírus da hepatite E genótipo 3 e o historial autoimune da mulher.
Subject(s)
Hepatitis E/diagnosis , Acute Disease , Adult , Autoimmune Diseases , Female , Humans , Severity of Illness IndexABSTRACT
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.
