A 46-year-old Caucasian man who worked as a mechanic was transferred to the gastroenterology out-patient clinic by the department of hematology, where he was regularly treated for B-CLL. The reason for the visit was a continuous increase of transaminases over the previous 7 months (months 0 to 7). The patient reported persistent exhaustion and occasional right-side abdominal pain. B-CLL had been diagnosed 4 years earlier (initially Binet stage B; actual blood cell counts: leukocytes 13.6/nL, thrombocytes 224/nL, and hemoglobin 16.3g/dL). Owing to increasing night sweats and compression of the urinary bladder by lymphomas 2 years earlier (leukocyte count 61/nL), he was treated with rituximab, pentostatin, and cyclophosphamide for 3 months, resulting in partial remission. Maintenance therapy was performed by using rituximab and was finally abandoned in month 4 of increased transaminases because of severe fatigue and susceptibility to infections, after which the patient took no medication. At the time of referral to our department, the patient was in stable partial remission and B symptoms were absent. He had no history of recent travels to countries outside Germany, contact with animals, or consumption of venison, liver sausage, or offal. He had not received a blood transfusion prior to the infection.\nNormal alanine transaminase (ALT) was documented in our patient until 10 months prior to his admission to the gastroenterology department. No ALT results are available in the 3-month interval from 10 months until 7 months prior to his transfer to the department of gastroenterology. Therefore, there is a 3-month window during which the first increase of transaminases must have occurred. An elevated ALT concentration of 234U/L was first detected 7 months before referral to the department of gastroenterology (the month of referral is denoted as “month 0”). After the initial discovery of increased transaminases, moderate fluctuating transaminitis – month 1: aspartate transaminase (AST) 61U/L, ALT 139U/L; month 3: AST 108U/L, ALT 220U/L; month 5: AST 142U/L, ALT 337U/L; and month 6: AST 161U/L, ALT 408U/L – was observed. Bilirubin concentrations were repeatedly within the reference interval. A diagnostic workup ruled out autoimmune and metabolic liver disease, hepatitis A-C, and herpes virus infection. A physical examination revealed enlarged axillary lymph nodes. The results of an abdominal ultrasound examination were otherwise unremarkable. Finally, HEV was diagnosed in a blood sample by detection of anti-HEV antibodies and HEV RNA (month 7: 3.0×105 copies/mL). Retrospectively, the presence of HEV RNA in serum was confirmed in two earlier samples (month 0: 2.0×107 copies/mL and month 6: 1.0×107 copies/mL). Samples from earlier visits were not available for analysis. Figure shows ALT concentrations, HEV viral load, and phases of immunosuppressive therapy over time. Sequence determination and phylogenetic analysis revealed a novel HEV genotype 3 strain clustering with other European subgenotype 3c isolates (Figure ).\nLaboratory analyses ordered 10 days after referral to our department showed that transaminases had rapidly decreased to concentrations within the reference intervals without therapeutic intervention (Figure ). Four weeks later (month 8), our patient was seen again in the department of hematology; transaminase concentrations were still normal, and HEV-RNA was not detectable from blood. Thus, it may be concluded that HEV infection was spontaneously cleared 7 to 8 months after the first referral. Lymphocyte counts in our patient’s blood were 0.8/nL at month 0, 0.7/nL at month 6, 9.4/nL at month 7, and 1.4/nL at month 8.
A 31-year old male patient underwent kidney transplantation due to hypoplastic kidneys in 1997. He developed a severe post-transplant lymphoma (PTLD) requiring chemotherapy (five cycles of RTX and high-dose cytarabine followed by another cycle of RTX monotherapy) in April 2013. In 2015, he experienced terminal renal graft failure leading to the discontinuation of post-transplant immunosuppression consisting of corticosteroids and mycophenolate mofetil. He suffered from immunoglobin deficiency treated with intravenous immunoglobin G substitutions. In May 2019, an abdominal ultrasound revealed a compensated liver cirrhosis. Extended laboratory testing revealed HEV infection which was also detectable in retained blood samples, confirming the diagnosis of a chronic hepatitis E. RBV treatment was initiated (dose of 200 mg/d), but had to be discontinued shortly after due to severe thrombocytopenia and the reduced general condition of the patient.\nsummarizes the underlying disease, immunosuppressive medication, time from last administration of RTX to HEV diagnosis, laboratory results, and HEV serology at the time of HEV diagnosis of the present patient cohort.\nshows the clinical course of HEV infection in our five patients, depicting the HEV load under the respective RBV treatment regimens and the development of HEV mutations associated with RBV resistance determined by Sanger sequencing. As depicted in , patient #1 exhibited hypogammaglobulinemia with decreased levels of IgG, IgA, and IgM. While expressing normal levels of CD19+ cells, class-switched memory B cells (CD19+ IgD-IgM-CD27+) were clearly diminished (0.2% of CD19+). In addition, patient #1 showed a profound T- and CD4-lymphopenia (190/µL absolute counts) and a low percentage of naïve CD4+ cells. In patient #2, no CD19+ B cells were detectable more than 12 months after the last RTX treatment. In agreement with the diagnosis of Waldenstrom’s disease, IgM levels were increased, while levels of IgG and IgA were reduced. Expressing only a mild T-lymphopenia, patient #2 also showed a relevant reduction in CD4+ cells (180/µL absolute cell count) and low naïve CD4+ cells. Patient #3 exhibited lower IgG trough levels and a complete reduction of IgA and IgM under immunoglobulin replacement therapy. No CD19+ B cells were detectable. Moreover, patient #3 also showed CD4-lymphopenia (100/µL absolute cell count) with low naïve CD4 cells. Patient #4 revealed hypogammaglobulinemia with reduced levels of IgG, IgA, and IgM with completely diminished CD19+ cells. In addition, patient #4 showed profound T- and CD4-lymphopenia (180/µL absolute counts) including a low percentage of naïve CD4+ cells (1%). According to his clinical files, patient #5 had normal immunoglobulin levels after kidney transplantation and before the initiation of PTLD chemotherapy. After chemotherapy the patient expressed constant hypogammaglobulinemia with IgG levels as low as 0.75 g/L, IgA levels of 0.2 and no detectable IgM levels. Finally, patient #5 also showed complete B-lymphopenia, NK-lymphopenia, and a severe T-lymphopenia with an absolute CD4 count of 50/µL.\nIn summary, all patients exhibited relevant hypogammaglobulinemia and T-lymphopenia following RTX-containing treatment regimens in the past.\nHEV subgenotypes and potential RBV treatment failure-associated mutations are listed in .