Acute liver failure probably due to hepatitis E: A diagnostic and therapeutic challenge

Background: Hepatitis E is endemic in some developing countries and may occur as imported or sporadic hepatitis in Hungary. This enterovirus-induced infection usually causes a self-resolving hepatitis; although, it may be fatal, especially in pregnant women. Case Report: We report here the case of a 54-year-old Hungarian woman who presented with painless jaundice 6 weeks after a journey in Turkey. There was no known liver disease in her history. The liver function tests showed a pronounced increase in conjugated bilirubin and marked increases in the serum aminotransferase levels (ASAT: 1795, ALAT: 1247U/l) with moderately elevated serum alkaline phosphatase and gamma-glutamyltransferase activitities. Her first routine viral serology was negative. There was no evidence of any biliary, autoimmune or drug-induced disease. The serum ceruloplasmin level was low, however, the suspicion of a Wilson's disease could be excluded by urinary copper excretion studies. A second virological testing revealed a positivity for immunoglobulin M to hepatitis E virus. Unfortunately, testing for hepatitis E virus RNA was not available. Her bilirubin level subsequently increased to a maximum of 639µmol/l, and her prothrombin level lowered to a minimum of 2.9 INR. From the third week on, hepatic encephalopathy and ascites were also manifested. The treatment was essentially supportive and symptomatic in manner. As complications, bacterial and then fungal infections were occurred; these were successfully treated with antibiotics and antimycotics. From the 3rd month of admission her liver function tests began to improve, and she was discharged 3 months after the admission. The jaundice and liver function test abnormalities resolved after a period of 6 months. Conclusion: This case shows that the diagnosis of hepatitis E may be challenging. It also indicates that hepatitis E can take a fulminant course not only in pregnant women, leading to severe impairment of liver function with the danger of death to liver failure.