Chronic hepatitis E: an important entity for clinicians to be aware of.

We read with interest the recent article by Miller and colleagues1 that highlighted a case of bilateral neuralgic amyotrophy in a patient who acquired hepatitis E from livestock. They provided a concise review of the epidemiology of hepatitis E and its acute clinical manifestations.

One important concept that we would like to highlight is that, although hepatitis E is predominantly an acute, self-limited infection with uncommon cases of liver failure, as reported by the authors, chronic hepatitis E infection can occur in patients who are immunosuppressed with substantial morbidity.2

Chronic hepatitis E was first reported in 2008 in transplant recipients; most cases have been reported in Europe, although a few have been reported in North America.3 Although most common in transplant recipients, chronic hepatitis E has also been reported in patients requiring immunosuppression for rheumatological conditions2 and in patients with hematological conditions.3

Diagnosis of chronic hepatitis E (assessed by the simultaneous assessment for anti-hepatitis E antibodies and hepatitis E RNA) is often under-recognized as many patients are asymptomatic, and the infection may only be recognized with abnormal results from liver tests. Chronic hepatitis E can lead to rapid progression of liver disease with the possibility of developing cirrhosis within 2 years.4 A history of direct farm exposure may be lacking as hepatitis E is predominately acquired through ingestion of undercooked pork products. Treatment of chronic hepatitis E is challenging; the current first-line therapy is reduction of immunosuppression (often a difficult prospect for transplant recipients and other patients on immunosuppression therapy) and oral ribavirin for a minimum of 3 months,5 with limited options for patients who do not respond to treatment.

Awareness of chronic hepatitis E is critical in the management of populations who are immunosuppressed and should be an important consideration on the differential diagnosis with abnormal results from liver tests. Early identification, staging and treatment — coordinated by experts in hepatology and infectious disease — are important to reduce the risk of adverse outcomes for patients with chronic hepatitis E.