What is the management of Hepatitis E?

Management of Hepatitis E Infection

The management of hepatitis E virus (HEV) infection primarily involves supportive care in immunocompetent individuals, with ribavirin being the treatment of choice for severe acute cases and chronic infection in immunocompromised patients. 1

Diagnosis

• HEV testing should be performed in:

  • Any patient with biochemical evidence of hepatitis
  • Suspected drug-induced liver injury
  • Decompensated chronic liver disease
  • Patients with neuralgic amyotrophy or Guillain-Barré syndrome
  • Encephalitis cases
  • Patients with unexplained acute neurology and raised ALT
  • Immunocompromised patients with persistently abnormal ALT 1

• Diagnostic approach:

  • Serology: Anti-HEV IgM and IgG antibodies (may be undetectable in immunocompromised patients)
  • Nucleic acid amplification testing (NAT): Detection of HEV RNA in blood or stool (gold standard, especially for immunocompromised patients) 1

Treatment Based on Clinical Presentation

Acute HEV Infection in Immunocompetent Patients

• Most cases are self-limiting and require only supportive care 1, 2
• Monitor liver function tests, hydration status, and nutritional support
• Avoid hepatotoxic medications and alcohol
• For severe acute hepatitis E or acute-on-chronic liver failure:
  • Ribavirin may be considered (C2 level recommendation) 1
  • Typical course: 3 weeks for severe acute hepatitis E 1

Chronic HEV Infection in Immunocompromised Patients

1. First step: Reduction of immunosuppression

   • Especially targeting T-cell-directed immunosuppressants
   • This approach achieves viral clearance in approximately one-third of cases 1

2. If viral persistence after immunosuppression reduction:

   • Ribavirin monotherapy for 3 months
   • Monitor HEV RNA in serum and stool
   • If relapse occurs after stopping ribavirin, consider longer treatment course 1

3. For liver transplant patients with persistent infection:

   • Pegylated interferon for 3 months may be considered 1

Special Populations

Pregnant Women

• HEV infection (particularly genotype 1) can cause severe outcomes in pregnancy
• Higher risk of fulminant hepatitis, with mortality rates up to 30% 3
• Ribavirin is contraindicated in pregnancy 1, 4
• Management is primarily supportive care 1

Patients with Extrahepatic Manifestations

• HEV testing is recommended in patients with neuralgic amyotrophy and Guillain-Barré syndrome (B1 recommendation) 1
• For HEV-associated glomerular disease:
  • Test for proteinuria in HEV-infected patients
  • Consider renal biopsy for new-onset proteinuria
  • Antiviral treatment with ribavirin is suggested for chronic HEV with glomerular disease 1

Monitoring and Follow-up

• For acute infection: Monitor until clinical and biochemical resolution
• For chronic infection on treatment: Regular monitoring of HEV RNA in serum and stool
• After treatment completion: Check for sustained virological response (SVR) and possible relapse

Prevention

• Good personal and environmental hygiene
• Safe water supply
• Proper cooking of meat products, especially pork
• HAV vaccination is recommended for high-risk populations 1
• HEV vaccine is available in China but not widely available globally 2, 5

Clinical Pitfalls and Caveats

• HEV can be misdiagnosed as drug-induced liver injury
• Antibody testing may be negative in immunocompromised patients; NAT testing is essential
• Ribavirin is the most effective treatment but is contraindicated in pregnancy
• Chronic infection only occurs in immunocompromised patients
• Extrahepatic manifestations (neurological, renal, hematological) may occur and should be monitored
• Consider HEV in cases of unexplained hepatitis, especially in returning travelers from endemic areas

By following this algorithmic approach to HEV management, clinicians can effectively diagnose and treat this increasingly recognized viral infection while minimizing complications and improving outcomes.