A 64-year old male with elevated aminotransferases presented himself at our outpatient clinic. He had been diagnosed with a monoclonal gammopathy of undetermined significance in 1992. In 2012, he had received eight cycles of bendamustine and RTX for Waldenstrom macroglobulinemia. Due to a relapse in 2016 he had been retreated with six cycles of bendamustine and RTX until February 2017, with stable remission since then. In November 2017, elevated aminotransferases were noted for the first time and the patient reported a short period of jaundice and fatigue. Extended laboratory testing revealed a HEV load of 6.1 E7 copies/mL. HEV IgG was positive and HEV IgM negative. After three months of persistent HEV replication, weight-based RBV treatment was started at a dose of 800 mg/d leading to virus clearance after three months of RBV treatment. RBV was stopped, but HEV relapsed only one month later and the patient was retreated with 800 mg RBV/d for an additional three months, achieving a sustained virological response.
A 68-year old male patient had been diagnosed with marginal zone lymphoma in 2011. He had received chemotherapy (R-CHOP) and autologous hematopoietic stem cell transplantation in 2012. After recurrence of his lymphoma in 2015 he had been treated with ibrutinib from 2015 to 2017 followed by bendamustine and RTX from January to October 2018. He had increased aminotransferases in March 2019, and HEV RNA was measured at 43 mio copies/mL in June 2019, prompting the initiation of treatment with ribavirin at a dose of 600 mg/d, which led to HEV clearance in July 2019. RBV treatment was terminated and the patient showed no HEV replication in October 2019. In November 2019, a viral relapse was detected and retreatment with 600 mg RBV/d was initiated.