S2453 Nice to Meat Your New Liver: A Unique Case of Hepatitis E

INTRODUCTION: Hepatitis E virus (HEV) infection in immunosuppressed patients carries high mortality if left untreated. HEV is primarily a hepatotropic virus but can affect the central nervous system, peripheral nervous system, renal system and hematologic system. Immunosuppressed patients who fail to clear the virus can develop chronic hepatitis if infected with HEV genotype 3 or 4, requiring treatment. We report a patient with HEV infection shortly after orthotopic liver transplantation. CASE DESCRIPTION/METHODS: A 48-year-old gentleman presented to the clinic with generalized weakness and fatigue for 1-month associated with myalgia that worsened by the end of the day. He underwent orthotopic liver transplant due to end-stage-liver disease from alcohol 4 months before current presentation and was maintained on triple therapy immunosuppression. Initial exam revealed normal vitals, pale conjunctiva but otherwise benign physical exam. Pertinent labs included WBC 3.9, hemoglobin 13.0, platelet 106, BUN 44, creatinine 1.4, AST 66, ALT 178, tacrolimus level 8, immuknow 134. Liver work-up revealed negative autoimmune antibodies, immunity to hepatitis A and B, and positive hepatitis E IgM. Quantitative HEV PCR was 757,000. Abdominal ultrasound with doppler revealed patent portal and hepatic vessels, and normal hepatic artery resistive indices. Diagnosis of acute hepatitis E infection in a hepatic allograft recipient was made. The source of the infection was traced back to an infected animal meat that patient had consumed 4 weeks prior to symptom onset. Patient was treated with ribavirin and his immunosuppression was adjusted. He recovered completely with normalization of liver enzymes and undetectable HEV PCR after 6 weeks. DISCUSSION: HEV infection is predominantly via fecal-oral transmission route and has been associated with animal meat consumption particularly deer, swine and chicken. The European Association for the Study of the Liver (EASL) guidelines suggest HEV testing in patients with unexplained flares of chronic liver disease and in all immunosuppressed patients with unexplained abnormal liver function tests. Solid organ transplant recipients who are viremic for more than 3 months after HEV infection are regarded as chronically infected and considered for treatment with ribavirin or peg-interferon alfa-2a. Our case illustrates the importance of testing for HEV infection in all patients with symptoms consistent with acute hepatitis infection, particularly in immunosuppressed individuals.