Acute Hepatitis E Infection in a Visitor to Louisiana

[Guest guest]

http://www.medscape.com/viewarticle/510351_1

South Med J. 2005;98(7):721-722

Acute Hepatitis E Infection in a Visitor to Louisiana

Posted

, Jr MD, PHD; Todd Brown, MD; Lanier

Hagood, MD; Cassidy, MD, Department of Internal Medicine,

Louisiana State University Health Sciences Center, Earl K. Long Memorial

Hospital, 5825 Airline Highway, Baton Rouge, LA

Abstract and Introduction

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.

Introduction

Acute hepatitis E (HEV) 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 and

had marked right upper quadrant and lower back tenderness. The metabolic

panel and complete blood count were normal, but the total bilirubin was 20.4

mg/dL (<1.3 mg/dL), alanine aminotransferase was 2,899 U/L (<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) 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 was 35 mg/dL (16 to 35.6 mg/dL). There were undetectable serum

levels of acetaminophen 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.

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 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 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.

Reprint Address

Reprint requests to Dr. M. Cassidy, Earl K. Long Memorial Hospital,

5825 Airline Highway, Baton Rouge, LA 70805. Email: wcassi@...

[Guest guest]

http://www.medscape.com/viewarticle/510351_1

South Med J. 2005;98(7):721-722

Acute Hepatitis E Infection in a Visitor to Louisiana

Posted

, Jr MD, PHD; Todd Brown, MD; Lanier

Hagood, MD; Cassidy, MD, Department of Internal Medicine,

Louisiana State University Health Sciences Center, Earl K. Long Memorial

Hospital, 5825 Airline Highway, Baton Rouge, LA

Abstract and Introduction

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.

Introduction

Acute hepatitis E (HEV) 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 and

had marked right upper quadrant and lower back tenderness. The metabolic

panel and complete blood count were normal, but the total bilirubin was 20.4

mg/dL (<1.3 mg/dL), alanine aminotransferase was 2,899 U/L (<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) 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 was 35 mg/dL (16 to 35.6 mg/dL). There were undetectable serum

levels of acetaminophen 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.

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 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 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.

Reprint Address

Reprint requests to Dr. M. Cassidy, Earl K. Long Memorial Hospital,

5825 Airline Highway, Baton Rouge, LA 70805. Email: wcassi@...

[Guest guest]

http://www.medscape.com/viewarticle/510351_1

South Med J. 2005;98(7):721-722

Acute Hepatitis E Infection in a Visitor to Louisiana

Posted

, Jr MD, PHD; Todd Brown, MD; Lanier

Hagood, MD; Cassidy, MD, Department of Internal Medicine,

Louisiana State University Health Sciences Center, Earl K. Long Memorial

Hospital, 5825 Airline Highway, Baton Rouge, LA

Abstract and Introduction

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.

Introduction

Acute hepatitis E (HEV) 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 and

had marked right upper quadrant and lower back tenderness. The metabolic

panel and complete blood count were normal, but the total bilirubin was 20.4

mg/dL (<1.3 mg/dL), alanine aminotransferase was 2,899 U/L (<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) 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 was 35 mg/dL (16 to 35.6 mg/dL). There were undetectable serum

levels of acetaminophen 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.

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 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 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.

Reprint Address

Reprint requests to Dr. M. Cassidy, Earl K. Long Memorial Hospital,

5825 Airline Highway, Baton Rouge, LA 70805. Email: wcassi@...

[Guest guest]

http://www.medscape.com/viewarticle/510351_1

South Med J. 2005;98(7):721-722

Acute Hepatitis E Infection in a Visitor to Louisiana

Posted

, Jr MD, PHD; Todd Brown, MD; Lanier

Hagood, MD; Cassidy, MD, Department of Internal Medicine,

Louisiana State University Health Sciences Center, Earl K. Long Memorial

Hospital, 5825 Airline Highway, Baton Rouge, LA

Abstract and Introduction

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.

Introduction

Acute hepatitis E (HEV) 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 and

had marked right upper quadrant and lower back tenderness. The metabolic

panel and complete blood count were normal, but the total bilirubin was 20.4

mg/dL (<1.3 mg/dL), alanine aminotransferase was 2,899 U/L (<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) 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 was 35 mg/dL (16 to 35.6 mg/dL). There were undetectable serum

levels of acetaminophen 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.

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 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 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.

Reprint Address

Reprint requests to Dr. M. Cassidy, Earl K. Long Memorial Hospital,

5825 Airline Highway, Baton Rouge, LA 70805. Email: wcassi@...