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Acute hepatitis E infection in a visitor to Louisiana.



Abstract: A man from Africa had been visiting Mississippi and Louisiana when he had development of acute hepatitis. Although hepatitis E is endemic to many parts of the world and has been associated with large outbreaks, it has remained relatively uncommon in this country. With growing foreign travel and an ever-increasing number of cases reported nationally, hepatitis E infection should be considered more frequently in the differential diagnosis of acute hepatitis.

Key Words: acute hepatitis, hepatitis E virus, travel medicine

**********

Acute hepatitis E (HEV HEV
abbr.
hepatitis E virus



HEV

hemagglutinating encephalomyelitis virus of pigs.
) infection is endemic in Asia, Africa, and Central America (1-5) and is becoming more frequent in Japan. (6) In the past few years, a number of cases have been reported in Americans returning from abroad as well as in visitors from endemic areas traveling to the United States. (7-12) We report a recent case of an African man visiting Louisiana and Mississippi. Although HEV antibody has been found in rats from Louisiana, (13) this is believed to be the first active human case reported in the state.

Case Report

A 31-year-old man from Cameroon was visiting southern Mississippi for about 3 weeks before the sudden onset of nausea, vomiting, and abdominal and lower back pain. Upon physical examination, the patient was deeply jaundiced jaun·diced  
adj.
1. Affected with jaundice.

2. Yellow or yellowish.

3. Affected by or exhibiting envy, prejudice, or hostility.


jaundiced
Adjective

1.
 and had marked right upper quadrant right upper quadrant Physical exam The abdominal region that contains the liver, duodenum and head of pancreas  and lower back tenderness. The metabolic panel and complete blood count were normal, but the total bilirubin Bilirubin

The predominant orange pigment of bile. It is the major metabolic breakdown product of heme, the prosthetic group of hemoglobin in red blood cells, and other chromoproteins such as myoglobin, cytochrome, and catalase.
 was 20.4 mg/dL (<1.3 mg/dL), alanine aminotransferase was 2,899 U/L U/L Upload
U/L Uplink
U/L Universal/Local
U/L Units/Litre
 (<46 U/L), and aspartate aminotransferase was 2,815 U/L (<45 U/L). Except for his country of origin, he reported no risk factors for viral hepatitis. Hepatitis A (HAV HAV hepatitis A virus.

HAV
abbr.
hepatitis A virus


HAV Hepatitis A virus, see there
) total antibody was positive, but the HAV IgM antibody was negative. Hepatitis B core total antibody was positive, whereas the core IgM antibody and surface antigen were negative. Hepatitis C antibody was negative. The ceruloplasmin ceruloplasmin /ce·ru·lo·plas·min/ (se-roo?lo-plaz´min) an a2-globulin of plasma believed to function in copper transport and its maintenance at appropriate levels in tissue; levels are decreased in Wilson's disease.  was 35 mg/dL (16 to 35.6 mg/dL). There were undetectable serum levels of acetaminophen acetaminophen (əsēt'əmĭn`əfĭn), an analgesic and fever-reducing medicine similar in effect to aspirin. It is an active ingredient in many over-the-counter medicines, including Tylenol and Midol.  and ethanol, and the antinuclear antibody titer was less than 1:40. Abdominal ultrasound showed normal liver size and flow patterns within the hepatic veins, portal veins, and inferior vena cava inferior vena cava
n. Abbr. IVC
A large vein formed by the union of the two common iliac veins that receives blood from the lower limbs and the pelvic and abdominal viscera and empties into the right atrium of the heart.
. Liver biopsy revealed diffuse areas of inflammation with minimal iron deposits and without fibrosis. Supportive treatment was given, and the hospital course was uneventful, with a rapid improvement in both symptoms and liver enzymes. Given his country of origin, HEV was suspected and a serum sample was sent to the National Center for Infectious Diseases. HEV IgM antibody was positive, and on follow-up several weeks later the patient was asymptomatic with normal liver enzymes.

Discussion

Hepatitis E is an icosahedral icosahedral

a regular polyhedron with 20 triangular faces, 12 corners and 30 sides, having cubic symmetry with 5:3:2-fold axes. A common structural form for the capsid of many viruses including herpesviruses, adenoviruses, parvoviruses, reoviruses, picornaviruses and retroviruses.
 nonenveloped single-stranded RNA virus that is spread fecal-orally. Infections occur in endemic areas and sporadically in nonendemic areas. Epidemiology differs from HAV infection primarily by age group. Although both are spread fecal-orally, HAV typically occurs in children, whereas HEV patients tend to be older. This patient is typical in that there is evidence of past HAV infection, but HEV infection occurred in the adult. Epidemics have been associated with contaminated water supplies, (14) and sporadic cases may have animal intermediates. Although the reservoir is unknown and several animals have been linked to contact transmission, (15-18) person-to-person transmission is thought to be rare. (19) The incubation period has been reported to be as little as 2 weeks, with continued virus excretion in stool for up to 2 weeks after the onset of illness. The disease course is typically mild to moderate in severity and lasts only a few weeks. No evidence of chronic infection has been reported. (20,21) The overall case fatality rate case fatality rate
n.
The proportion of individuals contracting a disease who die of that disease.
 is less than 3%, (22) with the main exception being pregnant women, in which mortality rates are as high as 20% during the third trimester. (23)

Although hepatitis E is endemic to many parts of the world and has been associated with large outbreaks, it has remained relatively uncommon in this country. Although the two most common genotypes are Asian/Burmese (genotype 1) and Mexican (genotype 2), at least one genotype (genotype 3) has been isolated that is unique to the United States, (24) suggesting that endemic infection in this country is possible.

With growing foreign travel and an ever-increasing number of cases reported nationally, the prevalence may begin to rise; therefore, hepatitis E infection should be considered more frequently in the differential diagnosis of acute hepatitis.

Conclusion

Prevention is the same for any enterically transmitted infection. This includes good hygiene, sanitary handling of food and water, and only eating cooked food. Immunoglobulin from endemic areas has not been shown to confer protection, (25) and supportive measures remain standard of care with therapy.

References

1. Tandon BN, Joshi YK, Jain SK, et al. An epidemic of non-A, non-B hepatitis non-A, non-B hepatitis
n. Abbr. NANB hepatitis
Hepatitis that is caused by a virus that is antigenically different from hepatitis viruses A and B.
 in North India. Indian J Med Res 1982;75:739-744.

2. Belabbes EH, Bouguermouh A, Benatallah A, et al. Epidemic non-A, non-B hepatitis in Algeria: strong evidence for its spreading by water. J Med Virol 1985;16:257-263.

3. Arankalle VA, Chadha MS, Mehendale SM, et al. Outbreak of enterically transmitted non-A, non-B hepatitis among school children. Lancet 1988;2:1199-1200.

4. Velazquez O, Stetler HC, Avila C, et al. Epidemic transmission of enterically transmitted non-A, non-B hepatitis in Mexico, 1986-1987. JAMA JAMA
abbr.
Journal of the American Medical Association
 1990;263:3281-3285.

5. Tsega E, Krawczynski K, Hansson BG, et al. Outbreak of acute hepatitis E virus infection among military personnel in northern Ethiopia. J Med Virol 1991;34:232-236.

6. Yatsuhashi H. Epidemiological and clinical features of hepatitis E in Japan. J Gastroenterol 2004;39:702-703.

7. Hepatitis E among US travelers, 1989-1992. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg,  1993;42:1-4.

8. Fortier D, Treadwell TL, Koff RS, et al. Enterically transmitted non-A, non-B hepatitis: importation from Mexico to Massachusetts. N Engl J Med 1989;320:1281-1282.

9. Dawson GJ, Mushahwar IK, Chan KH, et al. Detection of long-lasting antibody to hepatitis E virus in a US traveler to Pakistan. Lancet 1992;34:426-427.

10. Tsang TH, Denison EK, Williams HV, et al. Acute hepatitis E infection acquired in California. CID Cid or Cid Campeador (sĭd, Span. thēth kämpāäthōr`) [Span.,=lord conqueror], d. 1099, Spanish soldier and national hero, whose real name was Rodrigo (or Ruy) Díaz de Vivar.  2000;30:618-619.

11. Herrera JL. Hepatitis E as a cause of non-A, non-B hepatitis. Arch Intern Med 1993;153:773-775.

12. Bader TF, Krawczynski K, Polish LB, et al. Hepatitis E in a US traveler to Mexico. N Engl J Med 1991;325:1659.

13. Kabrane-Lazizi Y, Fine JB, Elm J, et al. Evidence for widespread infection of wild rats with hepatitis E virus in the United States. Am J Trop Med Hyg 1999;61:331-335.

14. Viswanath R. Infectious hepatitis in Delhi (1955-1965): a critical study. Indian J Med Res 1957;45:1-29.

15. Arankalle VA, Chobe LP, Joshi MV, et al. Human and swine hepatitis E viruses from Western India belong to different genotypes. J Hepatol 2002;36:417-425.

16. Tei S, Kitajima N, Takahashi K, et al. Zoonotic Zoonotic
A disease which can be spread from animals to humans.

Mentioned in: Zoonosis
 transmission of hepatitis E virus from deer to human beings. Lancet 2003;362:371-373.

17. Banks M, Bendall R, Grierson S, et al. Human and porcine porcine /por·cine/ (por´sin) pertaining to swine.

porcine

pertaining to pig. See also hog (1), swine.


porcine circovirus 1
a nonpathogenic virus.
 hepatitis E strains, United Kingdom. Emerg Infect Dis 2004;10:953-955.

18. Okamoto H, Takahashi M, Nishizawa T, et al. Presence of antibodies to hepatitis E virus in Japanese pet cats. Infection 2004;32:57-58.

19. Zuckerman AJ. Hepatitis E virus: the main cause of enterically transmitted non-A, non-B hepatitis. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift  1990;300:1475-1476.

20. Khuroo MS, Saleem M, Teli MR, et al. Failure to detect chronic liver disease Chronic liver disease is a liver disease of slow process and persisting over a long period of time, resulting in a progressive destruction of the liver.

It includes amongst others:
  • Cirrhosis of the liver
  • Alcoholic liver disease
  • Chronic hepatitis C
 after epidemic non-A, non-B hepatitis. Lancet 1980;2:97-98.

21. Krawczynski K. Hepatitis E. Hepatology 1993;17:932-941.

22. Enterically transmitted non-A, non-B hepatitis, East Africa. MMWR 1987;36:241-244.

23. World Health Organization, Hepatitis E. <http://www.who.int/media-centre/factsheets/fs280/en/> (accessed September 2004).

24. Kwo PY, Schlauder GG, Carpenter HA, et al. Acute hepatitis E by a new isolate acquired in the United States. Mayo Clin Proc 1997;72:1133-1136.

25. Khuroo MS, Dar MY. Hepatitis E. Evidence for person-to-person transmission and inability of low dose immune serum globulin immune serum globulin
n.
A sterile solution of globulins derived from pooled human blood that contains antibodies that are normally present in the blood of adults, used as a passive immunizing agent against rubella, measles, and hepatitis A and as
 from an Indian source to prevent it. Indian J Gastroenterol 1992;11:113-116.

James Edward Walker, Jr., MD, PHD, Todd Martin Brown, MD, Thomas Lanier Hagood, MD, and William Morgan Cassidy, MD

From the Department of Internal Medicine, Louisiana State University Louisiana State University and Agricultural and Mechanical College, generally known as Louisiana State University or LSU, is a public, coeducational university located in Baton Rouge, Louisiana and the main campus of the Louisiana State University System.  Health Sciences Center, Earl K. Long Memorial Hospital, 5825 Airline Highway, Baton Rouge, LA.

Reprint requests to Dr. William M. Cassidy, Earl K. Long Memorial Hospital, 5825 Airline Highway, Baton Rouge, LA 70805. Email: wcassi@lsuhsc.edu

Accepted November 22, 2004.

RELATED ARTICLE: Key Points

* Hepatitis E virus infection is usually benign and self-limited.

* There is a higher fatality rate in pregnant women.

* Hepatitis E virus should be considered in the differential diagnosis of acute viral hepatitis with negative serology Serology

The division of biological science concerned with antigen-antibody reactions in serum. It properly encompasses any of these reactions, but is often used in a limited sense to denote laboratory diagnostic tests, especially for syphilis.
 for hepatitis A, B, and C viruses.

* Person-to-person transmission is rare.
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Title Annotation:Case Report
Author:Cassidy, William Morgan
Publication:Southern Medical Journal
Date:Jul 1, 2005
Words:1455
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