gms | German Medical Science

Introduction: Hepatitis E virus (HEV) infection is one of the most common causes of acute viral hepatitis with an average incidence rate of 19.2% in Europe [1]. Hepatitis E has been increasingly recognized in immunosuppressed patients but whether patients with rheumatic diseases are at greater risk for severe disease or subsequent chronic liver disease is discussed controversially. No reports are available on the infection with HEV in patients with systemic vasculitis.

Methods: We report five cases of patients with ANCA-associated vasculitis (AAV) and acute infection with HEV who presented to our rheumatology clinic between 2009 and 2021. Patients’ data have been analyzed by retrospective chart review.

Results: Three of five patients had granulomatosis with polyangiitis (GPA) while two had eosinophilic granulomatosis with polyangiitis (EGPA) (Table 1 [Tab. 1]). All patients were under immunosuppressive therapy when acute HEV infection occurred. Testing for hepatitis A, B, and C as well as EBV and CMV was negative. Three patients received cyclophosphamide (CYC), one additionally rituximab (RTX) and one mepolizumab (Table 2 [Tab. 2]). Four patients reported clinical hepatitis symptoms and three had an increased BVAS score indicating active vasculitis. All patients with overt hepatitis had at least one potentially hepatotoxic medication, either their immunosuppressant, a recent antibiotic medication, or both. The course of acute HEV infection was predominantly cytolytic with leading GPT/ALT, liver enzymes normalized roughly one month after they peaked (GPT/ALT 2612 ±621 U/L; GOT/AST 1476 ±364 U/L). The patient under ongoing CYC pulse therapy for remission induction was the only one with temporary liver failure. All patients cleared the virus after cessation of immunosuppression despite continuation of oral prednisolone in a mean daily dose of 8.1 ±2.2 mg. None of the patients required antiviral treatment. After acute HEV infection, none of the patients developed chronic liver disease, although one patient died after HEV infection due to cholangiocarcinoma.

Conclusion: HEV infection is a common cause of hepatitis and must be considered and tested in immunocompromised AAV patients with abnormal liver function tests. Despite potent immunosuppression, all reported patients cleared the virus after cessation of the immunosuppressant without additional anti-viral therapy and none of them developed chronic liver disease.

Disclosures: Die Autoren geben keine Interessenskonflikte an.