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Hepatitis E

Hepatitis E is a viral infection caused by the hepatitis E virus.


Presentation

In children, Hepatitis E infection does not produce symptoms. It mostly affects adults as this disease mimics hepatic illness with features such as fatigue, jaundice, nausea, emesis, fever, anorexia, hepatomegaly, and abdominal pain. The duration is 1 to 2 weeks. Rarely does this infection cause acute liver failure.

Splenomegaly
  • Histopathological features were a non-specific chronic hepatitis similar to those described in BLS and hepatitis-splenomegaly syndrome.[ncbi.nlm.nih.gov]
  • In contrast to humans, swine and other mammalian animal species infected by HEV generally remain asymptomatic, whereas chickens infected by avian HEV may develop a disease known as Hepatitis-Splenomegaly syndrome.[ncbi.nlm.nih.gov]
  • The avian HEV associated with Hepatitis-Splenomegaly syndrome in chickens is genetically and antigenically related to mammalian HEV, and likely represents a new genus in the family.[ncbi.nlm.nih.gov]
  • [Google Scholar] ) and hepatitis-splenomegaly syndrome (HSS) in North America (Shivaprasad, 2003 Shivaprasad, H.L. 2003. “ Hepatitis splenomegaly syndrome ”.[doi.org]
Fever
  • This disease used to be called "break-bone" fever because it sometimes causes severe joint and muscle pain that feels like bones are breaking. Health experts have known about dengue fever for more than 200 years.[niaid.nih.gov]
  • The prevalence rates of prodromal fever, fatigue, loss of appetite, and jaundice were 25.6%, 85.6%, 83.8%, and 92.8%, respectively.[ncbi.nlm.nih.gov]
  • Blood specimens were tested for alternative acute infectious hepatitis etiologies, specifically yellow fever and viral hemorrhagic fevers. All eight were negative for these alternative etiologies.[cdc.gov]
  • Symptoms Usually symptoms appear 2 to 9 weeks after exposure to the virus and include fever, fatigue, lack of appetite, abdominal pain, and jaundice. Treatment includes supportive care of symptoms.[iamat.org]
Malaise
  • A non-pregnant Canadian woman returning from India presented with a 1-week history of jaundice and malaise. Subsequently, she developed fulminant hepatic failure caused by hepatitis E virus (HEV).[ncbi.nlm.nih.gov]
  • We report the case of a 62-year-old Caucasian woman who was admitted with urinary retention and lower limb paraesthesia following a week's prodromal illness of headache and malaise.[ncbi.nlm.nih.gov]
  • Symptoms of hepatitis E resemble those of hepatitis A: Low-grade fever Malaise (feeling of ill-health) Anorexia (lack of appetite) Nausea Abdominal discomfort Dark colored urine Jaundice Hepatitis E is not known to cause chronic infection.[ashasexualhealth.org]
  • A 57-year-old woman came to Iizuka Hospital on March 12, 2005, with malaise and anorexia.[doi.org]
Weight Loss
  • Symptoms may include: abdominal pain loss of appetite weight loss nausea (and sometimes vomiting) fever and chills mild headache tiredness dark urine and pale faeces yellow skin and eyes (jaundice) (see image).[sahealth.sa.gov.au]
  • They include: fatigue flu-like symptoms dark urine pale stool abdominal pain loss of appetite unexplained weight loss yellow skin and eyes, which may be signs of jaundice Chronic hepatitis develops slowly, so these signs and symptoms may be too subtle[healthline.com]
Orthopnea
  • We report a 52-year-old man who presented with neck and shoulder pain followed by orthopnea and left arm weakness. Electrodiagnostic testing showed left phrenic neuropathy and denervation in bilateral C5 and C6 myotomes.[ncbi.nlm.nih.gov]
Vomiting
  • Cases were more likely to present with vomiting (OR 3.2, 9%CI 1.4-7.9) than controls; possibly due to selection bias.[ncbi.nlm.nih.gov]
  • Symptoms of hepatitis E infection include nausea, mild flu-like symptoms, abdominal pain, vomiting and aching joints and muscles, jaundice and fatigue.[news-medical.net]
  • If contracted, the hepatitis E virus can cause serious liver disease, resulting in fever, reduced appetite, nausea and vomiting, abdominal pain, itching, and death.[thedailymeal.com]
Nausea
  • Symptoms of hepatitis E infection include nausea, mild flu-like symptoms, abdominal pain, vomiting and aching joints and muscles, jaundice and fatigue.[news-medical.net]
  • If contracted, the hepatitis E virus can cause serious liver disease, resulting in fever, reduced appetite, nausea and vomiting, abdominal pain, itching, and death.[thedailymeal.com]
  • Typical signs and symptoms of hepatitis include jaundice (yellow discoloration of the skin and sclera of the eyes, dark urine and pale stools), anorexia (loss of appetite), an enlarged, tender liver (hepatomegaly), abdominal pain and tenderness, nausea[hepfi.org]
Abdominal Pain
  • Symptoms of hepatitis E infection include nausea, mild flu-like symptoms, abdominal pain, vomiting and aching joints and muscles, jaundice and fatigue.[news-medical.net]
  • Symptoms Usually symptoms appear 2 to 9 weeks after exposure to the virus and include fever, fatigue, lack of appetite, abdominal pain, and jaundice. Treatment includes supportive care of symptoms.[iamat.org]
  • If contracted, the hepatitis E virus can cause serious liver disease, resulting in fever, reduced appetite, nausea and vomiting, abdominal pain, itching, and death.[thedailymeal.com]
Loss of Appetite
  • The prevalence rates of prodromal fever, fatigue, loss of appetite, and jaundice were 25.6%, 85.6%, 83.8%, and 92.8%, respectively.[ncbi.nlm.nih.gov]
  • Typical signs and symptoms of hepatitis include jaundice (yellow discoloration of the skin and sclera of the eyes, dark urine and pale stools), anorexia (loss of appetite), an enlarged, tender liver (hepatomegaly), abdominal pain and tenderness, nausea[hepfi.org]
  • Symptoms of HEV include darkened urine, pale stools and jaundice, as well as nausea, loss of appetite, tiredness, abdominal pain and fever.[metro.co.uk]
  • Other signs including tiredness, fever, vomiting, nausea, abdominal pain and loss of appetite. HOW YOU CAN DETECT SYMPTOMLESS LIVER DISEASE? People with symptoms of Hepatitis E are advised to contact their GP.[express.co.uk]
Diarrhea
  • Shigella causes roughly 500,000 cases of diarrhea in the United States each year.[niaid.nih.gov]
  • If you experience vomiting or diarrhea, follow your doctor’s orders for hydration and nutrition. The hepatitis A vaccine is available to prevent this infection. Most children begin vaccination between ages 12 and 18 months.[healthline.com]
  • Patients with severe fever, anorexia, vomiting, diarrhea, bleeding, agitation, or coma were admitted, as were patients with a positive malaria rapid diagnostic test, hypoglycemia, or pregnancy.[cdc.gov]
  • Three of the five rabbits showed symptoms of hepatitis such as anorexia, lethargy, and diarrhea. All five animals in group H4-NJ703 excreted virus in their stool.[doi.org]
Jaundice
  • Histories of jaundice and jaundice-related death were also obtained. For the seroprevalence survey, a random sample of residents was identified from the list created during the census.[doi.org]
  • METHODS: A total of consecutive 267 pregnant women with jaundice were recruited. The jaundiced patients were classified as acute viral hepatitis (AVH) or acute liver failure (ALF).[ncbi.nlm.nih.gov]
  • Conclusions: Pregnant women with jaundice and acute viral hepatitis caused by HEV infection had a higher maternal mortality rate and worse obstetric and fetal outcomes than did pregnant women with jaundice and acute viral hepatitis caused by other types[doi.org]
  • BACKGROUND: In September 2016, three acutely jaundiced (AJS) pregnant women were admitted to Am Timan Hospital, eastern Chad.[ncbi.nlm.nih.gov]
  • A non-pregnant Canadian woman returning from India presented with a 1-week history of jaundice and malaise. Subsequently, she developed fulminant hepatic failure caused by hepatitis E virus (HEV).[ncbi.nlm.nih.gov]
Hepatomegaly
  • It mostly affects adults as this disease mimics hepatic illness with features such as fatigue, jaundice, nausea, emesis, fever, anorexia, hepatomegaly, and abdominal pain. The duration is 1 to 2 weeks.[symptoma.com]
  • Typical signs and symptoms of hepatitis include jaundice (yellow discoloration of the skin and sclera of the eyes, dark urine and pale stools), anorexia (loss of appetite), an enlarged, tender liver (hepatomegaly), abdominal pain and tenderness, nausea[hepfi.org]
Skin Lesion
  • Pathologic, virologic and immunologic investigations were carried out on biopsied skin lesion, and peripheral blood mononuclear cells between the 2nd and 3rd round of antiviral treatment and biopsied liver.[ncbi.nlm.nih.gov]
Dark Urine
  • Typical signs and symptoms of hepatitis include jaundice (yellow discoloration of the skin and sclera of the eyes, dark urine and pale stools), anorexia (loss of appetite), an enlarged, tender liver (hepatomegaly), abdominal pain and tenderness, nausea[hepfi.org]
  • Hepatitis E affects an estimated 20 million people around the world each year, with typical symptoms including jaundice, dark urine and pale stools, abdominal pain and tenderness, nausea and vomiting, fever, and an enlarged, tender liver.[reuters.com]
  • Symptoms may include: abdominal pain loss of appetite weight loss nausea (and sometimes vomiting) fever and chills mild headache tiredness dark urine and pale faeces yellow skin and eyes (jaundice) (see image).[sahealth.sa.gov.au]
Headache
  • We report the case of a 62-year-old Caucasian woman who was admitted with urinary retention and lower limb paraesthesia following a week's prodromal illness of headache and malaise.[ncbi.nlm.nih.gov]
  • Symptoms may include: abdominal pain loss of appetite weight loss nausea (and sometimes vomiting) fever and chills mild headache tiredness dark urine and pale faeces yellow skin and eyes (jaundice) (see image).[sahealth.sa.gov.au]
  • People infected with the seasonal flu virus feel miserable with fever, chills, muscle aches, coughing, congestion, headache and fatigue for a week or so.[niaid.nih.gov]
  • Clinical features can include fever, chills, jaundice, dark urine, anorexia, nausea, vomiting, abdominal pain, headache, myalgia, and arthralgia ( 1 – 3 ). In general, HEV infection is more likely to be subclinical in children ( 1 ).[doi.org]
  • Among the headache disorders, only medication overuse headache had a significant change in rates of 43·3%.[ncbi.nlm.nih.gov]
Flaccid Paralysis
  • Over 48 hours, he accrued multiple cranial nerves palsies and progressed to a flaccid paralysis necessitating admission to an intensive care unit.Cerebrospinal fluid (CSF) study showed 20 lymphocytes and raised protein.[ncbi.nlm.nih.gov]

Workup

The clinical assessment consists of the patient's history including recent travel, a physical exam, and the appropriate laboratory studies.

Laboratory tests

Severe presentations warrant comprehensive laboratory studies such as a complete blood count (CBC), blood cultures, and a complete metabolic panel (CMP) which includes liver function tests (LFTs). Measurements of the latter reveal that levels of serum alanine aminotransferase (ALT) are higher than the serum aspartate aminotransferase (AST), with both measuring at least 10 times the upper limit of normal. These distinct findings are indicative of acute viral hepatitis.

Ominous signs suggestive of liver failure are prolonged prothrombin time (PT), hyperbilirubinemia, and hypoalbuminemia.

Confirmatory tests

Diagnosis of this infection is confirmed by the presence of anti-HEV immunoglobulin M (IgM), which increases about a month post-infection [7]. Another test, reverse transcriptase polymerase chain reaction (RT-PCR), detects the HEV RNA in blood and stool [2].

Imaging

Abdominal ultrasonography may be performed to exclude extra hepatic pathologies.

Treatment

In patients with no underlying disease, the treatment of acute infection is symptomatic with adequate hydration and electrolyte replacement. However, severe cases may be treated with ribavirin, which causes improvement in LFTs [8].

Furthermore, ribavirin is also used in patients with chronic hepatitis E infection that persists after the reduction of immunosuppression [9]. Additionally, therapy with pegylated interferon alpha-2b in liver transplant recipients can successfully clear the viral RNA [10] [11]. However, this drug is associated with serious side effects such as organ rejection in transplant patients.

Prognosis

This self-limited infection is usually benign in immunocompetent non-pregnant individuals. However, in the obstetric population, the mortality rate is 20% with a high risk for liver failure.

The main group that is susceptible to chronic infection is comprised of liver transplant recipients undergoing immunosuppressive treatment [5] [6].

Etiology

The HEV is a member of the Hepeviridae family. Transmission of this virus occurs through the feco-oral route as contaminated water supplies are responsible for the majority of all infections. In industrialized countries, undercooked pork is a source of infection [1]. This virus is not spread through sexual or casual contact.

Epidemiology

Hepatitis E is prevalent worldwide especially in regions with poor sanitation. Specifically, developing areas surrounding the equator exhibit higher rates of this infection. Factors that lead to outbreaks include rainy weather, floods, and overpopulation. Additionally, in endemic areas the disease affects mostly adults in the 15 to 40 years age group [2].

Sex distribution
Age distribution

Pathophysiology

HEV is a small, non-enveloped, single-stranded RNA virus [3] that is transmitted as a water-borne pathogen in endemic regions whereas it is spread as a foodborne organism in developed countries [3] [4].

Prevention

Preventive strategies such as good personal hygiene should be practiced. All individuals should wash their hands properly especially after using the restroom and prior to handling food. Additionally, meat should be cooked thoroughly. Very importantly, endemic areas should enforce sanitary standards for public water.

China has approved a vaccine [12] for prevention of Hepatitis E.

Summary

Hepatitis E is a self-limiting, acute infection that is usually benign in healthy and non-pregnant individuals. It is caused by the hepatitis E virus (HEV), which is transmitted mainly through the fecal-oral route. The diagnosis is achieved through a detailed evaluation of the history, physical exam, and laboratory studies. Most patients are treated symptomatically while certain individuals will require treatment.

Patient Information

What is Hepatitis E?

This is an infection caused by the Hepatitis E a virus. This is spread through the fecal-oral route, especially in underdeveloped areas with poor sanitation.

What are the symptoms?

How is it diagnosed?

There is a blood test that looks for antibodies to the virus and another test that measures the virus,

How is it treated?

This usually resolves on its own. Individuals who have had liver transplants are treated with a drug called ribavirin.

How can it be prevented?

  • Practice good hygiene by washing hands thoroughly
  • Cook meat well
  • If traveling, only drink water from a closed bottle

References

Article

  1. Feagins AR, Opriessnig T, Guenette DK, Halbur PG, Meng XJ. Inactivation of infectious hepatitis E virus present in commercial pig livers sold in local grocery stores in the United States. Int J Food Microbiol. 2008;123:32-7.
  2. Hepatitis E. World Health Organization. http://www.who.int/mediacentre/factsheets/fs280/en/. Accessed October 19, 2016.
  3. Mushahwar IK. Hepatitis E virus: molecular virology, clinical features, diagnosis, transmission, epidemiology, and prevention. Journal of Medical Virology. 2008; 80(4):646-58.
  4. Purcell RH, Emerson SU. Hepatitis E: an emerging awareness of an old disease. Journal of Hepatology. 2008;48(3):494-503.
  5. Zhou X, de Man RA, de Knegt RJ, Metselaar HJ, Peppelenbosch MP, Pan Q. Epidemiology and management of chronic hepatitis E infection in solid organ transplantation: a comprehensive literature review. Reviews in Medical Virology. 2013;23(5): 295–304.
  6. Legrand-Abravanel F, Kamar N, Sandres-Saune K, Lhomme S, Mansuy JM, Muscari F, et al. Hepatitis E virus infection without reactivation in solid-organ transplant recipients, France. Emerging Infectious Diseases. 2011; 17(1):30-7.
  7. Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, Ijaz S, Izopet J, et al. Hepatitis E. Lancet. 2012; 379(9835):2477-88.
  8. Gerolami R, Borentain P, Raissouni F, Motte A, Solas C, Colson P. Treatment of severe acute hepatitis E by ribavirin. Journal of Clinical Virology. 2011;52(1):60-2.
  9. Wedemeyer H, Pischke S, Manns MP. Pathogenesis and treatment of hepatitis e virus infection. Gastroenterology. 2012; 142(6):1388-1397 e1.
  10. Kamar N, Rostaing L, Abravanel F, Garrouste C, Lhomme S, Esposito L, et al. Ribavirin therapy inhibits viral replication on patients with chronic hepatitis e virus infection. Gastroenterology. 2010; 139(5):1612-8.
  11. Haagsma EB, Riezebos-Brilman A, van den Berg AP, Porte RJ, Niesters HG. Treatment of chronic hepatitis E in liver transplant recipients with pegylated interferon alpha-2b. Liver Transplantation. 2010. 16(4):474-7.
  12. Park SB. Hepatitis E vaccine debuts. Nature. 2012;491 (7422):21–22.

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Last updated: 2019-07-11 22:30