Correspondence

Sporadic Hepatitis E in Austria

N Engl J Med 1998; 339:1554-1555November 19, 1998

Article

To the Editor:

The hepatitis E virus (HEV) is known to cause enterically transmitted epidemic and sporadic forms of hepatitis in tropical and subtropical countries. HEV has been reported occasionally in areas where the disease is not endemic1; however, such infections are predominantly associated with a history of travel to tropical or subtropical countries. Recently, HEV variants have been isolated in areas where the disease is not endemic, such as the United States (variant, HEV US-1).2 The impact of this finding on the incidence of hepatitis in Western Europe is unclear. We report a case of sporadic hepatitis E in Austria that was characterized by the rapid disappearance of antibodies to HEV (anti-HEV).

A 65-year-old man was admitted to our hospital for jaundice after vomiting repeatedly for five days. He reported having hepatitis A in the 1960s. He had not traveled outside Austria in more than six months and had had no contact with travelers or food from abroad. There had been no cases of hepatitis in his family. On admission, his liver-enzyme levels were considerably elevated (Table 1Table 1Results of Liver Tests in a Patient with Sporadic Hepatitis E.), and serologic tests ruled out infection with hepatitis A, B, or C virus and acute infection with cytomegalovirus or Epstein–Barr virus. On day 5 after admission, serologic tests for HEV infection were performed. Enzyme immunoassays for anti-HEV IgM and IgG antibodies were strongly positive. The patient recovered within a few days.

The specificity of the assay results was confirmed by Western blotting with four recombinant open-reading-frame (ORF) proteins (nucleic acids 5220 to 5820 of the ORF2 N-terminal; nucleic acids 5804 to 6390 of the ORF2 midsection; nucleic acids 6350 to 7130 of the ORF2 C-terminal; and nucleic acids 5100 to 5470 of ORF3) derived from an HEV isolate from Madras, India.3 The IgM-specific blot showed reactivity with the ORF2 N-terminal and ORF3; the IgG-specific blot showed reactivity with the ORF2 C-terminal, the ORF2 N-terminal, and ORF3. Control assays for anti-HEV IgM were negative on day 22. Unexpectedly, anti-HEV IgG antibodies were present only briefly: an anti-HEV IgG assay was only weakly positive on day 22 and was negative on day 56. The results of Western blotting for IgG remained positive.

The transient presence of anti-HEV, as assessed by a commercially available test, is an unusual finding. About 80 percent of patients with hepatitis E have positive tests for anti-HEV IgM, and the levels remain detectable for an average of six to seven weeks after the onset of illness.4 The duration of detectable anti-HEV IgG may range from less than 1 year to more than 14 years.4

Our case report demonstrates the presence of HEV in Western Europe. The transient presence of anti-HEV should be considered in the diagnostic workup of non-A, non-B, non-C hepatitis.

Harald C. Worm, M.D.
Herbert Wurzer, M.D.
General Hospital of Graz, 8036 Graz, Austria

Gert Frösner, M.D.
University of Munich, 80336 Munich, Germany

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   H. C. LEWIS, O. WICHMANN, E. DUIZER. (2010) Transmission routes and risk factors for autochthonous hepatitis E virus infection in Europe: a systematic review. Epidemiology and Infection 138:02, 145
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   Tuija Kantala, Leena Maunula, Carl-Henrik von Bonsdorff, Jaakko Peltomaa, Maija Lappalainen. (2009) Hepatitis E virus in patients with unexplained hepatitis in Finland. Journal of Clinical Virology 45:2, 109-113
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   Peer B. Christensen, Ronald E. Engle, Charlotte Hjort, Keld M. Homburg, Werner Vach, Jørgen Georgsen, Robert H. Purcell. (2008) Time Trend of the Prevalence of Hepatitis E Antibodies among Farmers and Blood Donors: A Potential Zoonosis in Denmark. Clinical Infectious Diseases 47:8, 1026-1031
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   Subrat Kumar Panda, Deepshi Thakral, Shagufta Rehman. (2007) Hepatitis E virus. Reviews in Medical Virology 17:3, 151-180
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   Chong Gee Teo. (2006) Hepatitis E indigenous to economically developed countries: to what extent a zoonosis?. Current Opinion in Infectious Diseases 19:5, 460-466
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   Shaojing Wei, Yangbin Xu, Meifang Wang, Shing Shun Tony To. (2006) Phylogenetic analysis of hepatitis E virus isolates in southern China (1994–1998). Journal of Clinical Virology 36:2, 103-110
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    Harald C Worm, Wim H.M van der Poel, Gerald Brandstätter. (2002) Hepatitis E: an overview. Microbes and Infection 4:6, 657-666
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    Peer B. Christensen, Ronald E. Engle, Svend Erik H. Jacobsen, Henrik B. Krarup, Jrgen Georgsen, Robert H. Purcell. (2002) High prevalence of hepatitis E antibodies among Danish prisoners and drug users. Journal of Medical Virology 66:1, 49-55
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    George G. Schlauder, Isa K. Mushahwar. (2001) Genetic heterogeneity of hepatitis E virus. Journal of Medical Virology 65:2, 282-292
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    J. Al-Azmeh, G. Frösner, Z. Darwish, H. Bashour, F. Monem. (1999) Hepatitis E in Damascus, Syria. Infection 27:3, 221-223
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