Journal of Clinical Virology 62 (2015) 118–121
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
VIROQAS
Deranged liver function tests in a patient with Hodgkin’s lymphoma Kathy K. Li a,∗ , Rory N. Gunson a , Christopher Lush b , Celia Aitken a a West of Scotland Specialist Virology Centre, Level 5, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow G31 2ER, United Kingdom b Raigmore Hospital Inverness
a r t i c l e
i n f o
Article history: Received 1 July 2014 Received in revised form 25 August 2014 Accepted 28 August 2014 Keywords: HEV chronic hepatitis immunocompromised lymphoma
1. Case history A 39-year old man presented in autumn 2012 with a dry cough, night sweats and weight loss and following investigation was found to have Hodgkin’s lymphoma. He was treated on the RATHL (Response Adjusted Therapy for Hodgkin’s Lymphoma) study protocol, receiving two courses of AVBD (doxorubicin, vincristine, bleomycin, dacarbazine), and having a negative PET scan was randomised to receive AVD. His disease progressed, however, and he required salvage therapy with two cycles of IVE (ifosfamide, epirubicin and etoposide), to be consolidated
∗ Corresponding author. Tel.: +44 0141 201 8725; fax: +44 0141 201 8723. E-mail address: [email protected] (K.K. Li). http://dx.doi.org/10.1016/j.jcv.2014.08.026 1386-6532/© 2014 Elsevier B.V. All rights reserved.
with an autologous stem cell transplant (SCT). On admission on 10 September 2013 for BEAM (carmustine, etoposide, cytarabine, melphalan) conditioning and transplant, his liver enzymes (LFTs) were noted to be raised (AST 143 U/L; ALT 444 U/L). Question 1: What are the differential diagnoses for acutely deranged LFTs in this patient and what investigations should be done? Question 2: What is the significance of HEV in this patient? Question 3: How should immunosuppressed patients with HEV be managed?
K.K. Li et al. / Journal of Clinical Virology 62 (2015) 118–121
VIROQAS Evidence-based opinion What are the differential diagnoses for acutely deranged LFTs in this patient and what investigations should be done? A full autoimmune and viral hepatitis screen is indicated in this patient. His autoimmune hepatitis screen (ANCA, ANA, antimitochondrial antibodies, anti-smooth muscle antibodies, LKM antibodies, liver cytosol 1 antibodies) was negative. A viral hepatitis screen comprising HBsAg, anti-HBcore antibody, HCV antibody, HCV antigen and HAV IgM, HEV IgM, HEV IgG and HEV PCR as well as PCR testing for CMV, EBV and adenovirus were performed. The only positive tests were HEV IgG and HEV IgM (Mikrogen 2.6, c/o 0.314 and >3, c/o 0.651, respectively) and HEV RNA was detected using RT-PCR (ct 22.08). Drug-induced liver injury and disease progression of his lymphoma were ruled out. Computed tomography of the abdomen was performed to assess whether there was hepatic infiltration. This showed only diffuse fatty infiltration of the liver. He received his SCT the same day his HEV results became available. (Fig. 1). 2. Background Hepatitis E is a non-enveloped single-stranded positive sense RNA virus belonging to the Hepeviridae family. Four different HEV genotypes are known to infect humans. HEV1 and HEV2 infect humans only, and are endemic in developing countries, Asia and Africa/Mexico, respectively, causing travel-related HEV in Europe and North America. HEV3 (endemic in North America and Europe) and HEV4 (endemic in Asia) are found in pigs, rodents, deer, wild boar, farmed rabbits and shellfish, and are therefore zoonoses in humans [1,2]. The past 10 years has seen a sharp rise in the number of autochthonous HEV infections, with indigenous HEV cases superseding that of travel-acquired HEV since 2010 in the UK [3]. Transmission of HEV1and HEV2 is mainly faecal-oral, and personto-person spread is rare, unlike hepatitis A [4]. HEV3 and HEV4 on the other hand are mainly foodborne (ingestion of undercooked pork) with cases of transmission via blood transfusions or organtransplants also described [5–7]. The incubation period of HEV ranges from 2 to 8 weeks, and less than 5% of infected immunocompetent patients become symptomatic [8]. Symptoms manifest as jaundice, myalgia, malaise, or flu-like-illness, and only rarely cause morbidity or mortality in healthy individuals. A notable exception is pregnant women, up to 20% of whom can develop fulminant hepatitis with acute HEV [9]. Acute HEV infection in patients with a background of chronic hepatitis can also be severe [10]. The past decade has seen recognition of an increasing clinical spectrum of HEV infection. For example, chronic hepatitis E in immunocompromised patients (e.g. solid-organ transplant recipients, haematological patients or HIV patients with AIDS), as defined as a persistent increase in liver-enzyme levels with the presence of HEV RNA in the serum for at least 6 months after the acute phase [11], has been described with increasing frequency. In addition, numerous extra-hepatic manifestations of HEV3 infection have been reported. Neurological complications include Guillain–Barré syndrome, encephalitis, ataxia, brachial neuritis, inflammatory polyradiculopathy and proximal myopathy, occur in up to 5.5% of patients, after both acute and chronic HEV [12]. Renal manifestations include membranoproliferative glomerulonephritis and IgA nephropathy [13]; while thrombocytopenia, and pure red cell aplasia have also been described [14,15]. Diagnosis of HEV relies on the detection of HEV IgM and IgG, both of which appear with the acute elevation of transaminases. However, there is substantial variation in the sensitivity and
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specificity of commercially available kits [16]. A recent study assessing the most commonly used commercial anti-HEV IgM and IgG using a panel of known positive HEV1 and HEV3 samples found the specificity of tests ranged from 84% (MP Biomedicals, Singapore, former Genelabs) to 99% (Wantai, PE2-assay; Beijing, China), and sensitivity ranged from 54% (Mikrogen recomWell old assay, Neuried, Germany) to 75% (Wantai) [17]. Of note, the Mikrogen recomWell HEV IgM and IgG tests are used in our laboratory, and use recombinant antigen from HEV1 and HEV3 only, although manufacturers state HEV2 and HEV4 are detected by cross-reactivity [18]. Additionally, the production of antibodies in the immunosuppressed population is unreliable and the majority of these patients are asymptomatic, with LFTs raised in the 100s rather than 1000s. It is recommended that in this group of patients, HEV RNA detection by PCR is used to diagnose as well as monitor HEV infection. The lack of a sensitive and specific screening test coupled with the lack of awareness of HEV infections has led to cases of HEV misdiagnosed as “drug-induced liver injury” in the past. In developing countries, improvement in sanitation is key to preventing HEV infection; HEV RNA being found in environmental sewage and seawater samples [4]. However in industrialised countries, where zoonotic HEV infections predominate, emphasis should be placed on the proper cooking of pork products and game; cooking at 71 ◦ C for at least 20 min inactivates HEV [19]. Alternative preventative measures including vaccine development against HEV have been successful in control of HEV epidemics. Vaccine HEV 239 (Hecolin; Xiamen Innovax Biotech, Xiamen, China), has now been licensed in China for use in healthy adults aged 16–65 (including pregnant women). This recombinant HEV vaccine encompasses the ORF 2 capsid protein from HEV1, and has demonstrated safety and efficacy against HEV1 and HEV4 in phase II trials [8,20]. However, its efficacy in the immunosuppressed population has not been assessed [8]. What is the significance of HEV in this patient? As mentioned above, chronic HEV has been described in various patient groups including solid-organ transplant (SOT) recipients, haematological patients and HIV patients with advanced disease. Once infected with HEV, chronicity is thought to occur in approximately 60% of at risk patients and is defined as a persistent increase in liver-enzyme levels with the presence of HEV RNA in the serum for at least 6 months after the acute phase [11]. Chronicity is mainly linked to an impaired T-cell response (especially the subsets CD2, CD3 and CD4) and to the severity and type of immunosuppression [11,21]. Immunosuppressed patients with chronic hepatitis E can have a rapid progression to liver fibrosis (within 1 year) and about 14% of these patients develop cirrhosis, liver failure and ultimately require transplantation [12,20]. To date HEV chronicity has only been documented with HEV3 and a single case with HEV4 [22], mainly in immunosuppressed patients. The predominance of HEV3 is likely due to reporting bias, as most studies have been from areas where HEV3 is endemic. The mode of transmission of HEV in immunosuppressed patients is as for the general population. Thus all transplant patients should be advised to cook pork products and game at 71 ◦ C for at least 20 min to inactivate HEV [18], or avoid these altogether. Additionally, in SOT and SCT patients, transmissions via the allograft or blood transfusion have been reported [5,6,23]. As blood products are not screened for HEV, this is a possible although rare route of transmission. Seroprevalance studies in healthy blood donors have detected antibodies against HEV (22–27%), and in some cases viraemia (0–0.07%) [24,25]. How should immunosuppressed patients with HEV be managed? Management of chronic HEV in immunosuppressed patients involves a step-wise approach; reduction of immunosuppression is first-line, with approximately a third of patients achieving sustained virological response (SVR). If immunosuppression
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K.K. Li et al. / Journal of Clinical Virology 62 (2015) 118–121
Fig. 1. Progression of HEV infection in patient. HEV infection was first diagnosed from a serum from 10. September 2013, but retrospective testing of bloods from 27 June 2013 showed HEV viraemia at this stage, along with elevated transaminases. He received his autologous SCT on the 10 September2013. Treatment with RBV was started on the 12 December 2013, after engraftment, but he remained viraemic one month later, a poor prognostic indicator for SCV (see text). Dose reduction of RBV was made in February for anaemia and treatment stopped on 3 March 2014. Low level viraemia at end of March prompted recommencement of RBV when Hb stabilised. He received a total of 6 months RBV and HEV RNA is now undetectable in May 2014 (abbreviations: AST, aspartate aminotransferase; ct, cycle threshold; Hb, haemoglobin; Lymph, lymphocyte count; SCT, stem cell transplant; WCC, white cell count).
HEV RNA (ct)
27 -June2013
10 -September -2013
26 -September - 2013
20Nov-ember 2013
12December2013
03January2014
15Jan-uary 2014
15February2014
27Mar-ch 2014
31April2014
15May2014
23.05
22.08
23.36
18.66
18.01
Not tested
35.42
35.93
600 mg BD
600 mg BD
600 mg BD
Not detected 400 mg/ 600 mg
Not detected 400 mg/ 600 mg
Not detected 400/ 600 mg
modulation is not feasible, or if HEV viraemia persists and LFTs remain deranged, therapy with ribavirin has been used successfully to treat chronic HEV. Ribavirin (RBV) is a guanosine analogue, the first synthetic antiviral to exhibit broad-spectrum antiviral properties and inhibits a number of RNA and DNA viruses [26]. Recently, the mechanism of RBV against HEV has been shown in vitro to deplete cellular pools of GTP, thereby inhibiting HEV replication [27]. It may also exert an immunomodulatory effect in HEV infection, including the maintenance of T-helper 1 cells response [26]. The main side effect of RBV is anaemia, and can be managed with dose reduction, erythropoietin or top-up blood transfusions. Although no standard dosing and treatment strategy has been established, a recent multi-centre retrospective case study has shown that RBV monotherapy of 600 mg once daily for 3 months is effective at clearing chronic HEV, achieving an SVR in 78% of cases (SVR is defined as undetectable HEV RNA in serum 6 months after termination of therapy) [20,28]. The only independent variable in predicting SVR was a higher lymphocyte count at initiation of therapy, although patients with viral clearance at 1 month after initiation of therapy were also more likely to achieve SVR. Although RBV has mainly been used to treat patients with chronic HEV it should be noted that it has also been used successfully in the treatment of patients with chronic liver disease who acquire severe acute HEV disease [10]. Other treatment strategies that have been used to treat chronic HEV include interferon alpha (IFN-␣), alone or in conjunction with RBV. However, IFN-␣ is contraindicated in certain organ transplant recipients as it can cause acute graft rejection and therefore is not the treatment of choice. Use of mycophenolate mofetil, an inhibitor of inosine monophosphate dehydrogenase, in heart transplant patients has been associated with HEV clearance and it has shown synergy when used with RBV in vitro against HEV replication [29,30].
400 mg/ 600 mg
3. Patient outcome Our patient was diagnosed with HEV first on a sample from the 10 September 2013. Retrospective testing of a stored serum sample from June 2013, when he had mildly raised ALT (200 U/L) was positive for HEV IgM, HEV IgG and HEV RNA (ct 23.05), indicating that he had been viraemic for at least 3 months. His LFTs and HEV RNA were monitored for another 3 months to see if he would clear the infection naturally. However, he had persisting viraemia (ct 17.92, 18.66 and 18 in samples from October, November and December respectively), fulfilling the criteria for chronic HEV. As reduction of immunosuppression was not possible, on 12 December he was commenced on RBV therapy, 600 mg BD (twice daily) (Fig. 1). His lymphocyte count was slightly low at 1.7 × 109 /l (normal range 1.5–4 × 109 /l). He continued on RBV therapy with dose adjustment for anaemia (600 mg mane, 400 mg nocte) but remained viraemic a month into treatment, a poor prognostic indicator for SVR [28]. On 2 March 2014, HEV RNA became undetectable in his blood; he had received 3 months RBV in total. A follow-up blood from the end of March detected low level viraemia (ct 35) and at this stage we were concerned that the patient had failed to mount an SVR. According to the recent case study by Kamar et al. [28], patients who fail to achieve an SVR after 3 months of treatment may benefit from a further 6 months of RBV therapy. The patient was restarted on RBV in April, receiving an additional 3 months of therapy. Two subsequent samples in May (1st and 15th) have been HEV PCR negative and he has seroreverted to HEV IgM negative in these samples. At the time of writing the patient still remains clear of HEV RNA in his blood. Unfortunately, he has had a relapse of Hodgkin’s lymphoma, and deliberation is being made of an allogeneic SCT for definitive treatment. We will continue to monitor for HEV viraemia; the limit of detection of our
K.K. Li et al. / Journal of Clinical Virology 62 (2015) 118–121
in-house HEV PCR assay based on published methods [31,32] is 500IU/ml, so a low level viraemia cannot be ruled out [33]. We will consider re-treatment with ribavirin if viraemia is again detected. Investigation for his source of HEV infection has not yielded any definitive answer. Our patient had received multiple blood products, but we were unable to test donor blood for HEV as he had received these at a different centre and it was too late to obtain donor samples for testing by the time he was diagnosed (he had been infected for at least 3 months). As he received an autologous SCT, introduction of HEV via the graft was not relevant. However, there has been a report of reactivation of HEV infection in a patient with acute lymphoblastic leukaemia and an allogeneic SCT [34]. Food questionnaires are notoriously difficult to ascertain, especially when the history spans into months. 4. Summary This case of chronic HEV in a haematological patient is a reminder of the necessity of testing for HEV in immunosuppressed patients with only mildly deranged LFTs. Although HEV infection was detected by serology as well as molecular techniques here, negative HEV serology in isolation should be interpreted cautiously. Chronicity is common in immunosuppressed patients and it is important to monitor LFTs and HEV viraemia; there should be a low threshold for starting treatment with ribavirin to prevent rapid progression to fibrosis. Extra-hepatic manifestations are also indications for HEV testing where no other causes can be found. Until there is evidence for vaccine efficacy in the immunocompromised, prevention of HEV infection should consist of advising transplant patients to ensure thorough cooking of meat products or avoidance of pork and game meats if this is not feasible. Funding None. Competing interests None. Ethical approval Not required, patient details anonymised. Acknowledgement The authors would like to thank Dr. Chris Lush for clinical information regarding this case. References [1] Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, IJaz S, Izopet J, et al. Hepatitis E. Lancet 2012;379:2477–88. [2] Goens SD, Perdue ML. Hepatitis E virus in humans and animals. Anim Health Res Rev 2004;5:145–56. [3] Ijaz S, Said B, Boxall E, Smit E, Morgan D, Tedder RS. Indigenous Hepatitis E in England and Wales from 2003 to 2012: evidence of an emerging novel phenotyoe of viruses. J Infect Dis 2014;209(8):1212–8. [4] Ishida S, Yoshizumi S, Ikeda T, Miyoshi M, Goto A, Matsubayashi K, et al. Detection and molecular characterisation of hepatitis E virus in clinical, environmental and putative animal sources. Arch Virol 2012;1579(12): 2363–8. [5] Khuroo MS, Kamili S, Yattoo GN. Hepatitis E virus may be transmitted through blood transfusions in an endemic area. J Gastroenterol Hepatol 2004;19(7):778–84. [6] Schlosser B, Stein A, Neuhaus R, Pahl S, Ramez B, Krüger DH, et al. Liver transplant from a donor with occult HEV infection induced chronic hepatitis and cirrhosis in the recipient. J Hepatol 2012;56(2):500–2.
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[7] Colson P, Borentain P, Queyriaux B, Kaba M, Moal V, Gallian P, et al. Pig liver sausage as a source of hepatitis E virus transmission to humans. J Infect Dis 2010;202:825–34. [8] Zhu FC, Zhang J, Zhang XF, Zhou C, Wang ZZ, Huang SJ, et al. Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a largescale, randomised, double-blind placebo-controlled, phase 3 trial. Lancet 2010;;379(9744):895–902. [9] Bhatia V, Singhal A, Panda SK, Acharya SK. A 20-year single-centre experience with acute liver failure during pregnancy: is the prognosis really worse? Hepatology 2008;48:1577–87. [10] Peron JM. Acute autochonous hepatitis E in western patients with underlying chronic liver disease: a role or ribavirin? J Hepatol 2011;54:1320–6. [11] Kamar N, Selves J, Mansuy JM, Ouezzani L, Peron JM, Guitard J, et al. Hepatitis E virus and chronic hepatitis in organ-transplant recipients. N Engl J Med 2008;358(8):811–7. [12] Kamar N, Bendall RP, Peron JM, Cintas P, Prudhomme L, Mansuy JM, et al. Hepatitis E virus and neurological disorders. Emerg Infect Dis 2011;17:173–9. [13] Kamar N, Weclawwiak H, Guilbeau-Frugier C, Legrand-Abravanel F, Cointault O, Ribes D, et al. Hepatitis E virus and the kidney in solid-organ transplant patients. Transplantation 2012;93:617–23. [14] Fourquet E, Mansuy JM, Bureau C, Recher C, Vinel JP, Izopet J, et al. Severe thrombocytopenia associated with acute autochthonous hepatitis E. J Clin Virol 2010;48:73–4. [15] Shah SA, Lal A, Idrees M, Hussain A, Jeet C, Malik FA, et al. Hepatitis E virusassociated aplastic anaemia: the first case of its kind. J Clin Virol 2012;54:96–7. [16] Legrand-Abravanel F, Mansuay JM, Dubois M, Kamar N, Peron JM, Rostaing L, et al. Hepatitis E virus genotype 3 diversity, France. Emerg Infect Dis 2009;15:110–4. [17] Pas S, Roel HRA, Streefkerk Pronk M, de Man RA, Beersma MF, Osterhaus AD, et al. Diagnostic performance of selected commercial HEV IgM and IgG ELISAs for immunocompromised and immunocompetent patients. J Clin Virol 2013;58:629–34. [18] http://www.mikrogen.de/english/deutschland/products/testing-systems/ testsystem/hev-igg.html (accessed 31.03.14). [19] Barnaud E, Rogee S, Garry P, Rose N, Pavio N. Thermal inactivation of infectious hepatitis E virus in experimentally contaminated food. Appl Environ Microbiol 2012;78:5153–9. [20] Shrestha MP, Scott RM, Joshi DM, Mammen MP, Thapa GB, Thapa N, et al. Safety and efficacy of a recombinant hepatitis E vaccine. N Engl J Med 2007;356:895–903. [21] Kamar N, Abravanel F, Selves J, Garrouste C, Esposito L, Lavayssière L, et al. Influence of immunosuppressive therapy on the natural history of genotype3 hepatitis E virus infection after organ transplantation. Transplantation 2010;89(3):353–60. [22] Yansheng G, Zhang H, Huang W, Harrison JT, Geng K, Li Z, et al. Persistent Hepatitis E virus genotype 4 infection in a child with acute lymphoblastic leukaemia. Hepat Mon 2014;14(1):e15618. [23] Huzly D, Umhau M, Bettinger D, Cathomen T, Emmerich F, Hasselblatt P, et al. Transfusion-transmitted hepatitis E in Germany, 2013. Eurosurveillance 2014;19(21). http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId= 20812 (accessed 10.06.14). [24] Xu C, Alter HJ. An assessment of HEV prevalence and risk in U.S. blood donors and recipients. http://www3.niddk.nih.gov/fund/other/HepE2012/ HepatitisE2012ProgramBook.pdf [25] Slot E, Hogema BM, Riezebos-Brilman A, Kok TM, Molier M, Zaaijer HL. Silent hepatitis E virus infection in Dutch blood donors, 2011–2012. Eurosurveillance 2013;18:20550. [26] Graci J, Cameron CE. Mechanisms of action of ribavirin against distinct viruses. Rev Med Virol 2006;16:37–48. [27] Debing Y, Emerson SU, Wang Y, Pan Q, Balzarini J, Dallmeier K, et al. Ribavirin inhibits in vitro hepatitis E virus replication through depletion of cellular GTP pools and is moderately synergistic with alpha interferon. Antimicrob Agents Chemother 2014;58(1):267–73. [28] Kamar N, Izopet J, Tripon S, Bismuth M, Hillaire S, Dumortier J, et al. Ribavirin for Chronic Hepatitis E Virus Infection in Transplant Recipients. N Engl J Med 2014;370:1111–20. [29] Pischke S, Stiefel P, Franz B, et al. Chronic hepatitis E in heart transplant recipients. Am J Transplant 2012;12:3128–33. [30] Wang Y, Zhou X, Debing Y, et al. Calcineurin inhibitors stimulate and mycophenolic acid inhibits replication of hepatitis E virus. Gastroenterology 2014;146(7):1775–83. [31] Jothikumar N, Cromeans TL, Robertson BH, et al. A broadly reactive one-step real-time RT-PCR assay for rapid and sensitive detection of hepatitis E virus. J Virol Methods 2006;131(1):64–71. [32] Garson JA, Ferns RB, Grant PR, et al. Minor groove binder modification of widely used TaqMan probe for hepatitis E virus reduces risk of false negative real-time PCR results. J Virol Methods 2012;186(1–2):157–60. [33] Baylis SA, Hanschmann KM, Blumel J, Nubling CM. Standardisation of hepatitis E virus (HEV) nucleic acid amplification techniques-based assays: an initial study to evaluate a panel of HEV strains and investigate laboratory performance. J Clin Microbiol 2011;49:1234–9. [34] Le Coutre P, Meisel H, Hofman J, et al. Reactivation of hepatitis E infection in a patient with acute lymphoblastic leukaemia after allogeneic stem cell transplantation. Gut 2009;58:699–702.
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
VIROQAS
Deranged liver function tests in a patient with Hodgkin’s lymphoma Kathy K. Li a,∗ , Rory N. Gunson a , Christopher Lush b , Celia Aitken a a West of Scotland Specialist Virology Centre, Level 5, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow G31 2ER, United Kingdom b Raigmore Hospital Inverness
a r t i c l e
i n f o
Article history: Received 1 July 2014 Received in revised form 25 August 2014 Accepted 28 August 2014 Keywords: HEV chronic hepatitis immunocompromised lymphoma
1. Case history A 39-year old man presented in autumn 2012 with a dry cough, night sweats and weight loss and following investigation was found to have Hodgkin’s lymphoma. He was treated on the RATHL (Response Adjusted Therapy for Hodgkin’s Lymphoma) study protocol, receiving two courses of AVBD (doxorubicin, vincristine, bleomycin, dacarbazine), and having a negative PET scan was randomised to receive AVD. His disease progressed, however, and he required salvage therapy with two cycles of IVE (ifosfamide, epirubicin and etoposide), to be consolidated
∗ Corresponding author. Tel.: +44 0141 201 8725; fax: +44 0141 201 8723. E-mail address: [email protected] (K.K. Li). http://dx.doi.org/10.1016/j.jcv.2014.08.026 1386-6532/© 2014 Elsevier B.V. All rights reserved.
with an autologous stem cell transplant (SCT). On admission on 10 September 2013 for BEAM (carmustine, etoposide, cytarabine, melphalan) conditioning and transplant, his liver enzymes (LFTs) were noted to be raised (AST 143 U/L; ALT 444 U/L). Question 1: What are the differential diagnoses for acutely deranged LFTs in this patient and what investigations should be done? Question 2: What is the significance of HEV in this patient? Question 3: How should immunosuppressed patients with HEV be managed?
K.K. Li et al. / Journal of Clinical Virology 62 (2015) 118–121
VIROQAS Evidence-based opinion What are the differential diagnoses for acutely deranged LFTs in this patient and what investigations should be done? A full autoimmune and viral hepatitis screen is indicated in this patient. His autoimmune hepatitis screen (ANCA, ANA, antimitochondrial antibodies, anti-smooth muscle antibodies, LKM antibodies, liver cytosol 1 antibodies) was negative. A viral hepatitis screen comprising HBsAg, anti-HBcore antibody, HCV antibody, HCV antigen and HAV IgM, HEV IgM, HEV IgG and HEV PCR as well as PCR testing for CMV, EBV and adenovirus were performed. The only positive tests were HEV IgG and HEV IgM (Mikrogen 2.6, c/o 0.314 and >3, c/o 0.651, respectively) and HEV RNA was detected using RT-PCR (ct 22.08). Drug-induced liver injury and disease progression of his lymphoma were ruled out. Computed tomography of the abdomen was performed to assess whether there was hepatic infiltration. This showed only diffuse fatty infiltration of the liver. He received his SCT the same day his HEV results became available. (Fig. 1). 2. Background Hepatitis E is a non-enveloped single-stranded positive sense RNA virus belonging to the Hepeviridae family. Four different HEV genotypes are known to infect humans. HEV1 and HEV2 infect humans only, and are endemic in developing countries, Asia and Africa/Mexico, respectively, causing travel-related HEV in Europe and North America. HEV3 (endemic in North America and Europe) and HEV4 (endemic in Asia) are found in pigs, rodents, deer, wild boar, farmed rabbits and shellfish, and are therefore zoonoses in humans [1,2]. The past 10 years has seen a sharp rise in the number of autochthonous HEV infections, with indigenous HEV cases superseding that of travel-acquired HEV since 2010 in the UK [3]. Transmission of HEV1and HEV2 is mainly faecal-oral, and personto-person spread is rare, unlike hepatitis A [4]. HEV3 and HEV4 on the other hand are mainly foodborne (ingestion of undercooked pork) with cases of transmission via blood transfusions or organtransplants also described [5–7]. The incubation period of HEV ranges from 2 to 8 weeks, and less than 5% of infected immunocompetent patients become symptomatic [8]. Symptoms manifest as jaundice, myalgia, malaise, or flu-like-illness, and only rarely cause morbidity or mortality in healthy individuals. A notable exception is pregnant women, up to 20% of whom can develop fulminant hepatitis with acute HEV [9]. Acute HEV infection in patients with a background of chronic hepatitis can also be severe [10]. The past decade has seen recognition of an increasing clinical spectrum of HEV infection. For example, chronic hepatitis E in immunocompromised patients (e.g. solid-organ transplant recipients, haematological patients or HIV patients with AIDS), as defined as a persistent increase in liver-enzyme levels with the presence of HEV RNA in the serum for at least 6 months after the acute phase [11], has been described with increasing frequency. In addition, numerous extra-hepatic manifestations of HEV3 infection have been reported. Neurological complications include Guillain–Barré syndrome, encephalitis, ataxia, brachial neuritis, inflammatory polyradiculopathy and proximal myopathy, occur in up to 5.5% of patients, after both acute and chronic HEV [12]. Renal manifestations include membranoproliferative glomerulonephritis and IgA nephropathy [13]; while thrombocytopenia, and pure red cell aplasia have also been described [14,15]. Diagnosis of HEV relies on the detection of HEV IgM and IgG, both of which appear with the acute elevation of transaminases. However, there is substantial variation in the sensitivity and
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specificity of commercially available kits [16]. A recent study assessing the most commonly used commercial anti-HEV IgM and IgG using a panel of known positive HEV1 and HEV3 samples found the specificity of tests ranged from 84% (MP Biomedicals, Singapore, former Genelabs) to 99% (Wantai, PE2-assay; Beijing, China), and sensitivity ranged from 54% (Mikrogen recomWell old assay, Neuried, Germany) to 75% (Wantai) [17]. Of note, the Mikrogen recomWell HEV IgM and IgG tests are used in our laboratory, and use recombinant antigen from HEV1 and HEV3 only, although manufacturers state HEV2 and HEV4 are detected by cross-reactivity [18]. Additionally, the production of antibodies in the immunosuppressed population is unreliable and the majority of these patients are asymptomatic, with LFTs raised in the 100s rather than 1000s. It is recommended that in this group of patients, HEV RNA detection by PCR is used to diagnose as well as monitor HEV infection. The lack of a sensitive and specific screening test coupled with the lack of awareness of HEV infections has led to cases of HEV misdiagnosed as “drug-induced liver injury” in the past. In developing countries, improvement in sanitation is key to preventing HEV infection; HEV RNA being found in environmental sewage and seawater samples [4]. However in industrialised countries, where zoonotic HEV infections predominate, emphasis should be placed on the proper cooking of pork products and game; cooking at 71 ◦ C for at least 20 min inactivates HEV [19]. Alternative preventative measures including vaccine development against HEV have been successful in control of HEV epidemics. Vaccine HEV 239 (Hecolin; Xiamen Innovax Biotech, Xiamen, China), has now been licensed in China for use in healthy adults aged 16–65 (including pregnant women). This recombinant HEV vaccine encompasses the ORF 2 capsid protein from HEV1, and has demonstrated safety and efficacy against HEV1 and HEV4 in phase II trials [8,20]. However, its efficacy in the immunosuppressed population has not been assessed [8]. What is the significance of HEV in this patient? As mentioned above, chronic HEV has been described in various patient groups including solid-organ transplant (SOT) recipients, haematological patients and HIV patients with advanced disease. Once infected with HEV, chronicity is thought to occur in approximately 60% of at risk patients and is defined as a persistent increase in liver-enzyme levels with the presence of HEV RNA in the serum for at least 6 months after the acute phase [11]. Chronicity is mainly linked to an impaired T-cell response (especially the subsets CD2, CD3 and CD4) and to the severity and type of immunosuppression [11,21]. Immunosuppressed patients with chronic hepatitis E can have a rapid progression to liver fibrosis (within 1 year) and about 14% of these patients develop cirrhosis, liver failure and ultimately require transplantation [12,20]. To date HEV chronicity has only been documented with HEV3 and a single case with HEV4 [22], mainly in immunosuppressed patients. The predominance of HEV3 is likely due to reporting bias, as most studies have been from areas where HEV3 is endemic. The mode of transmission of HEV in immunosuppressed patients is as for the general population. Thus all transplant patients should be advised to cook pork products and game at 71 ◦ C for at least 20 min to inactivate HEV [18], or avoid these altogether. Additionally, in SOT and SCT patients, transmissions via the allograft or blood transfusion have been reported [5,6,23]. As blood products are not screened for HEV, this is a possible although rare route of transmission. Seroprevalance studies in healthy blood donors have detected antibodies against HEV (22–27%), and in some cases viraemia (0–0.07%) [24,25]. How should immunosuppressed patients with HEV be managed? Management of chronic HEV in immunosuppressed patients involves a step-wise approach; reduction of immunosuppression is first-line, with approximately a third of patients achieving sustained virological response (SVR). If immunosuppression
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Fig. 1. Progression of HEV infection in patient. HEV infection was first diagnosed from a serum from 10. September 2013, but retrospective testing of bloods from 27 June 2013 showed HEV viraemia at this stage, along with elevated transaminases. He received his autologous SCT on the 10 September2013. Treatment with RBV was started on the 12 December 2013, after engraftment, but he remained viraemic one month later, a poor prognostic indicator for SCV (see text). Dose reduction of RBV was made in February for anaemia and treatment stopped on 3 March 2014. Low level viraemia at end of March prompted recommencement of RBV when Hb stabilised. He received a total of 6 months RBV and HEV RNA is now undetectable in May 2014 (abbreviations: AST, aspartate aminotransferase; ct, cycle threshold; Hb, haemoglobin; Lymph, lymphocyte count; SCT, stem cell transplant; WCC, white cell count).
HEV RNA (ct)
27 -June2013
10 -September -2013
26 -September - 2013
20Nov-ember 2013
12December2013
03January2014
15Jan-uary 2014
15February2014
27Mar-ch 2014
31April2014
15May2014
23.05
22.08
23.36
18.66
18.01
Not tested
35.42
35.93
600 mg BD
600 mg BD
600 mg BD
Not detected 400 mg/ 600 mg
Not detected 400 mg/ 600 mg
Not detected 400/ 600 mg
modulation is not feasible, or if HEV viraemia persists and LFTs remain deranged, therapy with ribavirin has been used successfully to treat chronic HEV. Ribavirin (RBV) is a guanosine analogue, the first synthetic antiviral to exhibit broad-spectrum antiviral properties and inhibits a number of RNA and DNA viruses [26]. Recently, the mechanism of RBV against HEV has been shown in vitro to deplete cellular pools of GTP, thereby inhibiting HEV replication [27]. It may also exert an immunomodulatory effect in HEV infection, including the maintenance of T-helper 1 cells response [26]. The main side effect of RBV is anaemia, and can be managed with dose reduction, erythropoietin or top-up blood transfusions. Although no standard dosing and treatment strategy has been established, a recent multi-centre retrospective case study has shown that RBV monotherapy of 600 mg once daily for 3 months is effective at clearing chronic HEV, achieving an SVR in 78% of cases (SVR is defined as undetectable HEV RNA in serum 6 months after termination of therapy) [20,28]. The only independent variable in predicting SVR was a higher lymphocyte count at initiation of therapy, although patients with viral clearance at 1 month after initiation of therapy were also more likely to achieve SVR. Although RBV has mainly been used to treat patients with chronic HEV it should be noted that it has also been used successfully in the treatment of patients with chronic liver disease who acquire severe acute HEV disease [10]. Other treatment strategies that have been used to treat chronic HEV include interferon alpha (IFN-␣), alone or in conjunction with RBV. However, IFN-␣ is contraindicated in certain organ transplant recipients as it can cause acute graft rejection and therefore is not the treatment of choice. Use of mycophenolate mofetil, an inhibitor of inosine monophosphate dehydrogenase, in heart transplant patients has been associated with HEV clearance and it has shown synergy when used with RBV in vitro against HEV replication [29,30].
400 mg/ 600 mg
3. Patient outcome Our patient was diagnosed with HEV first on a sample from the 10 September 2013. Retrospective testing of a stored serum sample from June 2013, when he had mildly raised ALT (200 U/L) was positive for HEV IgM, HEV IgG and HEV RNA (ct 23.05), indicating that he had been viraemic for at least 3 months. His LFTs and HEV RNA were monitored for another 3 months to see if he would clear the infection naturally. However, he had persisting viraemia (ct 17.92, 18.66 and 18 in samples from October, November and December respectively), fulfilling the criteria for chronic HEV. As reduction of immunosuppression was not possible, on 12 December he was commenced on RBV therapy, 600 mg BD (twice daily) (Fig. 1). His lymphocyte count was slightly low at 1.7 × 109 /l (normal range 1.5–4 × 109 /l). He continued on RBV therapy with dose adjustment for anaemia (600 mg mane, 400 mg nocte) but remained viraemic a month into treatment, a poor prognostic indicator for SVR [28]. On 2 March 2014, HEV RNA became undetectable in his blood; he had received 3 months RBV in total. A follow-up blood from the end of March detected low level viraemia (ct 35) and at this stage we were concerned that the patient had failed to mount an SVR. According to the recent case study by Kamar et al. [28], patients who fail to achieve an SVR after 3 months of treatment may benefit from a further 6 months of RBV therapy. The patient was restarted on RBV in April, receiving an additional 3 months of therapy. Two subsequent samples in May (1st and 15th) have been HEV PCR negative and he has seroreverted to HEV IgM negative in these samples. At the time of writing the patient still remains clear of HEV RNA in his blood. Unfortunately, he has had a relapse of Hodgkin’s lymphoma, and deliberation is being made of an allogeneic SCT for definitive treatment. We will continue to monitor for HEV viraemia; the limit of detection of our
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in-house HEV PCR assay based on published methods [31,32] is 500IU/ml, so a low level viraemia cannot be ruled out [33]. We will consider re-treatment with ribavirin if viraemia is again detected. Investigation for his source of HEV infection has not yielded any definitive answer. Our patient had received multiple blood products, but we were unable to test donor blood for HEV as he had received these at a different centre and it was too late to obtain donor samples for testing by the time he was diagnosed (he had been infected for at least 3 months). As he received an autologous SCT, introduction of HEV via the graft was not relevant. However, there has been a report of reactivation of HEV infection in a patient with acute lymphoblastic leukaemia and an allogeneic SCT [34]. Food questionnaires are notoriously difficult to ascertain, especially when the history spans into months. 4. Summary This case of chronic HEV in a haematological patient is a reminder of the necessity of testing for HEV in immunosuppressed patients with only mildly deranged LFTs. Although HEV infection was detected by serology as well as molecular techniques here, negative HEV serology in isolation should be interpreted cautiously. Chronicity is common in immunosuppressed patients and it is important to monitor LFTs and HEV viraemia; there should be a low threshold for starting treatment with ribavirin to prevent rapid progression to fibrosis. Extra-hepatic manifestations are also indications for HEV testing where no other causes can be found. Until there is evidence for vaccine efficacy in the immunocompromised, prevention of HEV infection should consist of advising transplant patients to ensure thorough cooking of meat products or avoidance of pork and game meats if this is not feasible. Funding None. Competing interests None. Ethical approval Not required, patient details anonymised. Acknowledgement The authors would like to thank Dr. Chris Lush for clinical information regarding this case. References [1] Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, IJaz S, Izopet J, et al. Hepatitis E. Lancet 2012;379:2477–88. [2] Goens SD, Perdue ML. Hepatitis E virus in humans and animals. Anim Health Res Rev 2004;5:145–56. [3] Ijaz S, Said B, Boxall E, Smit E, Morgan D, Tedder RS. Indigenous Hepatitis E in England and Wales from 2003 to 2012: evidence of an emerging novel phenotyoe of viruses. J Infect Dis 2014;209(8):1212–8. [4] Ishida S, Yoshizumi S, Ikeda T, Miyoshi M, Goto A, Matsubayashi K, et al. Detection and molecular characterisation of hepatitis E virus in clinical, environmental and putative animal sources. Arch Virol 2012;1579(12): 2363–8. [5] Khuroo MS, Kamili S, Yattoo GN. Hepatitis E virus may be transmitted through blood transfusions in an endemic area. J Gastroenterol Hepatol 2004;19(7):778–84. [6] Schlosser B, Stein A, Neuhaus R, Pahl S, Ramez B, Krüger DH, et al. Liver transplant from a donor with occult HEV infection induced chronic hepatitis and cirrhosis in the recipient. J Hepatol 2012;56(2):500–2.
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[7] Colson P, Borentain P, Queyriaux B, Kaba M, Moal V, Gallian P, et al. Pig liver sausage as a source of hepatitis E virus transmission to humans. J Infect Dis 2010;202:825–34. [8] Zhu FC, Zhang J, Zhang XF, Zhou C, Wang ZZ, Huang SJ, et al. Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a largescale, randomised, double-blind placebo-controlled, phase 3 trial. Lancet 2010;;379(9744):895–902. [9] Bhatia V, Singhal A, Panda SK, Acharya SK. A 20-year single-centre experience with acute liver failure during pregnancy: is the prognosis really worse? Hepatology 2008;48:1577–87. [10] Peron JM. Acute autochonous hepatitis E in western patients with underlying chronic liver disease: a role or ribavirin? J Hepatol 2011;54:1320–6. [11] Kamar N, Selves J, Mansuy JM, Ouezzani L, Peron JM, Guitard J, et al. Hepatitis E virus and chronic hepatitis in organ-transplant recipients. N Engl J Med 2008;358(8):811–7. [12] Kamar N, Bendall RP, Peron JM, Cintas P, Prudhomme L, Mansuy JM, et al. Hepatitis E virus and neurological disorders. Emerg Infect Dis 2011;17:173–9. [13] Kamar N, Weclawwiak H, Guilbeau-Frugier C, Legrand-Abravanel F, Cointault O, Ribes D, et al. Hepatitis E virus and the kidney in solid-organ transplant patients. Transplantation 2012;93:617–23. [14] Fourquet E, Mansuy JM, Bureau C, Recher C, Vinel JP, Izopet J, et al. Severe thrombocytopenia associated with acute autochthonous hepatitis E. J Clin Virol 2010;48:73–4. [15] Shah SA, Lal A, Idrees M, Hussain A, Jeet C, Malik FA, et al. Hepatitis E virusassociated aplastic anaemia: the first case of its kind. J Clin Virol 2012;54:96–7. [16] Legrand-Abravanel F, Mansuay JM, Dubois M, Kamar N, Peron JM, Rostaing L, et al. Hepatitis E virus genotype 3 diversity, France. Emerg Infect Dis 2009;15:110–4. [17] Pas S, Roel HRA, Streefkerk Pronk M, de Man RA, Beersma MF, Osterhaus AD, et al. Diagnostic performance of selected commercial HEV IgM and IgG ELISAs for immunocompromised and immunocompetent patients. J Clin Virol 2013;58:629–34. [18] http://www.mikrogen.de/english/deutschland/products/testing-systems/ testsystem/hev-igg.html (accessed 31.03.14). [19] Barnaud E, Rogee S, Garry P, Rose N, Pavio N. Thermal inactivation of infectious hepatitis E virus in experimentally contaminated food. Appl Environ Microbiol 2012;78:5153–9. [20] Shrestha MP, Scott RM, Joshi DM, Mammen MP, Thapa GB, Thapa N, et al. Safety and efficacy of a recombinant hepatitis E vaccine. N Engl J Med 2007;356:895–903. [21] Kamar N, Abravanel F, Selves J, Garrouste C, Esposito L, Lavayssière L, et al. Influence of immunosuppressive therapy on the natural history of genotype3 hepatitis E virus infection after organ transplantation. Transplantation 2010;89(3):353–60. [22] Yansheng G, Zhang H, Huang W, Harrison JT, Geng K, Li Z, et al. Persistent Hepatitis E virus genotype 4 infection in a child with acute lymphoblastic leukaemia. Hepat Mon 2014;14(1):e15618. [23] Huzly D, Umhau M, Bettinger D, Cathomen T, Emmerich F, Hasselblatt P, et al. Transfusion-transmitted hepatitis E in Germany, 2013. Eurosurveillance 2014;19(21). http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId= 20812 (accessed 10.06.14). [24] Xu C, Alter HJ. An assessment of HEV prevalence and risk in U.S. blood donors and recipients. http://www3.niddk.nih.gov/fund/other/HepE2012/ HepatitisE2012ProgramBook.pdf [25] Slot E, Hogema BM, Riezebos-Brilman A, Kok TM, Molier M, Zaaijer HL. Silent hepatitis E virus infection in Dutch blood donors, 2011–2012. Eurosurveillance 2013;18:20550. [26] Graci J, Cameron CE. Mechanisms of action of ribavirin against distinct viruses. Rev Med Virol 2006;16:37–48. [27] Debing Y, Emerson SU, Wang Y, Pan Q, Balzarini J, Dallmeier K, et al. Ribavirin inhibits in vitro hepatitis E virus replication through depletion of cellular GTP pools and is moderately synergistic with alpha interferon. Antimicrob Agents Chemother 2014;58(1):267–73. [28] Kamar N, Izopet J, Tripon S, Bismuth M, Hillaire S, Dumortier J, et al. Ribavirin for Chronic Hepatitis E Virus Infection in Transplant Recipients. N Engl J Med 2014;370:1111–20. [29] Pischke S, Stiefel P, Franz B, et al. Chronic hepatitis E in heart transplant recipients. Am J Transplant 2012;12:3128–33. [30] Wang Y, Zhou X, Debing Y, et al. Calcineurin inhibitors stimulate and mycophenolic acid inhibits replication of hepatitis E virus. Gastroenterology 2014;146(7):1775–83. [31] Jothikumar N, Cromeans TL, Robertson BH, et al. A broadly reactive one-step real-time RT-PCR assay for rapid and sensitive detection of hepatitis E virus. J Virol Methods 2006;131(1):64–71. [32] Garson JA, Ferns RB, Grant PR, et al. Minor groove binder modification of widely used TaqMan probe for hepatitis E virus reduces risk of false negative real-time PCR results. J Virol Methods 2012;186(1–2):157–60. [33] Baylis SA, Hanschmann KM, Blumel J, Nubling CM. Standardisation of hepatitis E virus (HEV) nucleic acid amplification techniques-based assays: an initial study to evaluate a panel of HEV strains and investigate laboratory performance. J Clin Microbiol 2011;49:1234–9. [34] Le Coutre P, Meisel H, Hofman J, et al. Reactivation of hepatitis E infection in a patient with acute lymphoblastic leukaemia after allogeneic stem cell transplantation. Gut 2009;58:699–702.
