ReviewClinical presentation of hepatitis E
Introduction
The term ‘hepatitis’ implies ‘inflammation of the liver’. Based on the duration of illness or associated laboratory abnormalities, it is subdivided, somewhat empirically, into acute hepatitis, i.e. lasting for up to 6 months, or chronic hepatitis, i.e. persisting for longer than 6 months.
Liver inflammation may be caused by one of several etiologic agents, including viruses and other infectious agents, drugs, alcohol and other toxins, autoimmune disease, radiation injury, etc.; in some cases, no known cause can be found. Currently, at least five distinct hepatotropic or hepatitis viruses, named using consecutive letters from the English language, are recognized. These viruses vary widely in their size, structure, genomic organization, and mode of replication.
HEV is a small 27–34 nm size virus with a nearly 7.2-kilobase, single-stranded RNA genome. Structure and molecular features of this virus are covered elsewhere in this supplement (Mitsuura et al., this issue, Jameel et al., this issue). At least four distinct genotypes of the virus (named as genotypes 1, 2, 3 and 4) are known. These four genotypes differ widely in geographical distribution and host species, as has been discussed in detail elsewhere in this supplement (Purdy et al., this issue). The virus is excreted in the stools of infected persons and is primarily transmitted through fecal-oral route (Aggarwal and Naik, 2009). The disease caused by HEV is termed as ‘hepatitis E’. This document reviews the clinical manifestations of hepatitis E, while recognizing that these often resemble those of acute hepatitis caused by other hepatotropic viruses.
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Epidemiologic patterns of HEV infection
HEV infection is associated with two distinct epidemiological patterns of disease, as has been reviewed in detail elsewhere recently (Aggarwal and Naik, 2009), as also in this review (Khuroo et al., this issue, Miyamura et al., this issue).
Hepatitis E is highly endemic in the Indian subcontinent, China, Southeast and Central Asia, the Middle East, and northern and western parts of Africa (Aggarwal and Naik, 2009). In these areas, outbreaks of hepatitis E of variable sizes have been reported. In
Clinical manifestations of hepatitis E
Data on clinical manifestations of hepatitis E are available from (i) two case reports of volunteers who ingested preparations that contained the causative virus, (ii) from reports of hepatitis E outbreaks and sporadic disease from highly endemic areas, and (iii) case reports and case series from developed countries with low endemicity. Each of these is discussed separately, followed by clinical manifestations of hepatitis E in pregnant women and neonates, and some unusual non-hepatic
Hepatitis E in pregnant women
Hepatitis E is characteristically associated with a high disease attack rate among pregnant women. In addition, the affected pregnant women are at a higher risk of developing FHF and death. This association was first reported during outbreaks in India (Khuroo, 1980, Vishwanathan and Sidhu, 1957, Wahi and Arora, 1953), but has also been found in sporadic cases in endemic areas (Khuroo et al., 1983).
In the Kashmir outbreak, 17.3%; 8.8%, 19.4% and 18.6% of pregnant women in the first, second and
Non-hepatic manifestations of hepatitis E
Several non-hepatic manifestations have been described in association with HEV infection (Table 3).
Factors influencing clinical severity of disease
Factors determining the severity of illness caused by HEV infection are not fully understood. These could include host factors or viral factors. Of these, host factors, in particular pregnancy, age and pre-existing liver disease clearly appear to be important, as has been discussed earlier. In addition, host immune response may also play a role.
Whether viral factors play a role remains unclear, particularly since subjects infected with the same strain of HEV during a water-borne outbreak show
Treatment of hepatitis E
Since hepatitis E is generally a self-limiting disease, drug treatment has not been considered in patients with acute hepatitis E, either uncomplicated or associated with acute liver failure. The treatment therefore is supportive, and directed primarily at relief of symptoms such as fever, body aches, vomiting, etc. Patients with liver failure need measures to control cerebral edema and consideration of liver transplantation. In pregnant women, termination of pregnancy has not proven benefit to
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