Q2: Answer: B
This patient has chronic hepatitis E infection, as demonstrated by the positive hepatitis IgG antibody. It is recommended that HEV RNA be identified in serum or stool for diagnosis of hepatitis E. However, HEV RNA PCR is not readily available outside of research settings and therefore the Centers for Disease Control and Prevention states that the diagnosis can be confirmed only by testing for the presence of antibody against HEV or HEV RNA. Providers must be aware of the possibility of false positives and negatives for HEV serologies.
In immunocompetent individuals, hepatitis E is generally a self-limited condition, but in solid-organ transplant recipients, chronic infection can ensue. Hepatitis E infection in solid-organ transplant recipients has been linked to consumption of game meat, pork, and mussels. The infection is largely asymptomatic, but occasionally presents with jaundice. The liver test elevations are mild, with ALT levels up to 300 U/L. Approximately 60% of transplant recipients who are infected with hepatitis E develop chronic infections.
The best treatment for chronic hepatitis E in solid-organ transplant recipients is ribavirin. In one study, the sustained virologic response rate was 78% after a course of approximately 3 months of ribavirin. Pegylated interferon has been used for treatment of hepatitis E, but has less evidence to support its use and has a less favorable side effect profile. Sofosbuvir is a treatment for hepatitis C and therefore is not correct, though there are recent data suggesting that sofosbuvir inhibits hepatitis E virus replication in vitro and results in an additive effect when combined with ribavirin.
Observation is not a correct answer, as about 10% of patients with chronic hepatitis E may develop cirrhosis. Although not one of the provided answers, lowering the overall immunosuppression would be part of the treatment approach in a solid-organ transplant recipient with chronic hepatitis E.
Reference
1. Kamar N., Izopet J., Tripon S., et al. Ribavirin for chronic hepatitis E virus infection in transplant recipients. N Engl J Med. 2014 Mar 20;370(12):1111-20.
2. Dao Thi V.L., Debing Y., Wu X. Sofosbuvir inhibits hepatitis E virus replication in vitro and results in an additive effect when combined with ribavirin. Gastroenterology. 2016 Jan;150(1):82-5.