Challenges in Diagnosing and Managing Hepatitis E in Transplant Recipients: A Case Report

TL;DR

This case report discusses the difficulty in diagnosing Hepatitis E in a kidney transplant recipient and highlights the possibility of spontaneous recovery without treatment.

Contribution

The case highlights the diagnostic challenges of HEV in immunosuppressed patients and the potential for spontaneous viral clearance.

Findings

HEV diagnosis in transplant recipients may require viral load testing due to potential serological negativity.

Spontaneous viral clearance is possible in HEV-infected immunosuppressed patients without targeted antiviral therapy.

Abstract

Hepatitis E virus (HEV) is a common but often underdiagnosed cause of hepatitis in both the general population and transplant patients. Diagnosis is usually made by detecting IgM anti‐HEV antibodies, with immunosuppressed individuals being at higher risk for chronic infection. We present the case of a 56‐year‐old man who developed asymptomatic liver cytolysis 4 months after a kidney transplant, with no significant physical findings or relevant epidemiological history. Abdominal ultrasound revealed hepatic steatosis. Drug‐induced liver injury was suspected, prompting the discontinuation of potential causative agents. However, liver enzymes worsened asymptomatically after 2 weeks, prompting further medication adjustments. Testing for Hepatitis B and C, as well as IgM for Toxoplasma, was negative. Serologies for herpes simplex and varicella zoster were positive for IgG and negative for IgM, and CMV viral load was undetectable. HEV serologies were negative for IgG and IgM. A liver biopsy revealed nonspecific acute hepatitis without fibrosis. The positive HEV plasma viral load was suggestive of Hepatitis E. As the patient was asymptomatic with no further analytical worsening, targeted treatment was not initiated. The patient achieved spontaneous viral clearance in less than 12 weeks, despite his immunocompromised condition. This case report highlights the diagnostic challenges of HEV hepatitis in immunosuppressed patients, as detection may rely solely on viral load testing due to potential serological negativity. This case also highlights that despite the patient′s immunosuppressed condition, viral clearance is possible without the need for targeted antiviral therapy.