Course of hepatitis E infection in a patient with rheumatoid arthritis and autoimmune hepatitis: A case report. Issue 51 (December 2017)

• Record Type: Journal Article
• Authors: Thodou, Victoria; Buechter, Matthias; Manka, Paul; Gerken, Guido; Kahraman, Alisan
• Other Names: NA. section editor.
• Is Part Of: Medicine. Volume 96:Issue 51(2017)
• Publication Date: 2017-12
• Subjects: autoimmune hepatitis -- hepatitis E virus -- immunosuppression; Medicine -- Periodicals; Medicine -- Periodicals; Médecine -- Périodiques; Geneeskunde; Medicine; Periodicals; Periodicals; 610.5
• DOI: 10.1097/MD.0000000000009407
• Languages: English
• ISSNs: 0025-7974

Abstract

Abstract: Rationale: A 62-year-old male patient was admitted to our clinic in February 2016 with persistently elevated liver enzymes. Patient concerns: Clinical history involved a long time of poly-autoimmunity with a rheumatoid arthritis (in remission under tocilizumab therapy), an autoimmune thyroiditis, an eosinophilia as well as a hyper-immunoglobulin (IgG) 4-syndrome. Diagnoses: Laboratory studies revealed a significant increase in liver enzymes with an alanine aminotransferase (ALT) level of 574 U/L and an aspartate aminotransferase (AST) level of 864 U/L (normal <50 U/L). Furthermore, the patient was positive for anti-nuclear autoantibodies (ANA) with a titer of 1:320 (normal upper limit: 1:80). Interventions: Liver histology, obtained via mini-laparoscopy, demonstrated lobular hepatitis with markedly increased hepatocyte apoptosis, lymphoplasmatic cell infiltration, and 20% microvascular fat without significant fibrosis, which strengthened the diagnosis of autoimmune hepatitis (AIH). Pulse steroid treatment with 100 mg prednisolone for 3 days followed by a tapering down was initiated. Follow-up laboratory analysis demonstrated a decrease in liver enzymes and also of the ANA-titer. Outcomes: At that point, hepatitis E virus (HEV) infection was diagnosed with a positive anti-HEV immunoglobulin M (IgM) antibody and HEV-ribonucleotide acid (RNA) of 6280 copies/mL. Lessons: Despite the HEV infection and due to the strength of autoimmunity, we decided to continue immunosuppressive therapy and monitored HEV-PCR regularly. However, HEV-RNA became negative after 2 months and HEV-IgM turned negative after 13 months.