A 63-year-old Swedish white man underwent orthotopic heart transplantation in July 2012 secondary to dilated cardiomyopathy. Preoperative liver enzymes and bilirubin were within normal ranges with the exception of a slightly elevated aspartate aminotransferase (AST; 1.3 times the upper limit of normal). He had an elevated prothrombin time-international normalized ratio (PT-INR) consistent with his warfarin treatment for atrial fibrillation. Virus serology was negative for hepatitis C virus and hepatitis B virus and he was immune against hepatitis A virus. In addition, he had antibodies against cytomegalovirus (CMV) and Epstein–Barr virus.\nThe surgery was complicated by excessive bleeding, which required administration of clotting factors, plasma and thrombocytes. Postoperatively, he developed a moderate worsening of a pre-existing renal insufficiency and thrombocytopenia. Also, a transient rise in bilirubin and liver enzymes was noted. The maintenance immunosuppressive therapy consisted of tacrolimus (target 6 to 8μg/L), everolimus (target 3 to 6μg/L), mycophenolate mofetil 1g twice a day and prednisolone 15mg daily. One month after surgery he was discharged with normal transaminases.\nAt 6-month follow-up, a marked elevation of liver enzymes was noted and, retrospectively, a borderline enzyme elevation was observed 2 months post-surgery (Fig. ). An abdominal ultrasound showed a suspected liver hemangioma, but was otherwise normal. Echocardiography revealed moderate pericardial effusion without hemodynamic compromise, and normal cardiac function. An endomyocardial biopsy showed no signs of significant rejection. Drug-induced hepatotoxicity was initially suspected because of a temporally related increase in simvastatin dosing, but discontinuation of this drug had no effect on his liver enzymes. Autoantibodies, antinuclear antibodies (ANA), smooth muscle antibodies (SMA) and antimitochondrial antibodies (AMA) for autoimmune hepatitis were all negative. He had not seroconverted in markers for hepatitis B or C infection. He had a low titer of CMV DNA in sera consistent with minor reactivation, which was absent at follow-up a week later.\nSerology for HEV was reactive for both anti-HEV-IgM and IgG-antibodies (recomWell HEV IgG/IgM enzyme-linked immunosorbent assay, Mikrogen Diagnostik, Germany), and HEV RNA (1.6×107 copies per mL) was detected in serum by quantitative polymerase chain reaction (PCR) [] at the 6-month follow-up. A retrospective investigation revealed that the patient was negative for anti-HEV and HEV RNA 2 months prior to surgery and at the day of surgery, but HEV RNA was detected 3 weeks post-surgery in the first available serum sample post-transplantation (Fig. ). At that time point, the serology for HEV was negative and remained negative for the next 9 weeks despite detectable HEV RNA. Both anti-HEV IgM and IgG were detectable in the next available serum sample, which was obtained 26 weeks post-surgery (Fig. ).\nSix months after surgery, the immunosuppressive therapy had been reduced, and consisted of tacrolimus (target 3 to 6μg/L), everolimus, (target 3 to 6μg/L), mycophenolate mofetil 0.5g twice a day, and prednisolone 7.5mg daily. After diagnosis of HEV infection, the dose of mycophenolate mofetil was reduced further to 0.25g twice a day and treatment with ribavirin initiated at a dosing of 800mg daily. Ribavirin therapy resulted in a rapid decline of liver enzymes and after 2 months of treatment, the level of HEV RNA in his serum dropped from 1.6×107 to 63 copies per mL (Fig. ). He then experienced an exacerbation of gout, which was treated by increasing prednisolone dosing to 20mg daily for 3 days followed by 10mg for another 3 days. During this period and up to 9 weeks afterwards HEV replication reactivated and the serum viral load increased to 2.3×104 copies per mL.\nRibavirin treatment was complicated by anemia with a decline in hemoglobin concentration from 13.6 to 10.7g/dL, and thus an increase in dosing to 1200mg daily had to be postponed for 1 month. On this treatment dosing, he cleared the HEV infection in 1.5 months and treatment with ribavirin continued for an additional 3 months (i.e. total treatment duration: 800mg/day for 4.5 months and 1200mg/day for 4.5 months), and a sustained virological response (SVR) was achieved. A liver biopsy 1 year later revealed lack of fibrosis and only minor, non-significant inflammation (grade 0 to 1 according to Batts–Ludwig classification).\nHE is a notifiable disease in Sweden, and possible routes of infection should be investigated. The patient lived and worked in Gothenburg and had not travelled outside Sweden during the last years. He reported no close contact with pigs or other animals, except for birds. No additional cases of HEV infection were diagnosed at the ward during his hospitalization. Sera from the heart donor was retrospectively investigated and found negative for both HEV RNA and anti-HEV IgG and IgM. During surgery and shortly thereafter, the patient received considerable amounts of blood-derived products including thrombocytes, clotting factors and plasma. The clotting factors were produced from a pharmaceutical company assuring that all blood products were tested and negative for HEV RNA in pooled samples. In total thrombocytes, erythrocytes and plasma from 17 different donors were administered to the patient. One year after the transplantation, all 17 donors were asked to provide a serum sample for serological investigation of HEV markers. Of the donors, 12 accepted, and among them, one had detectable anti-HEV IgG. This donor had anti-HEV IgG at a high titer, but had undetectable anti-HEV IgM and HEV RNA in serum. Despite repeated efforts, the remaining five donors did not provide serum samples.\nTo obtain the gt and an indication of the origin of the infecting strain, the viral genome was amplified, sequenced and phylogenetically analyzed in the polymerase region of ORF1 as previously described []. A phylogenetic tree based on the sequences obtained and the corresponding genomic region in 120 HEV strains obtained from GenBank showed that the infecting virus from the transplanted patient was a HEV strain belonging to gt 3. This strain was found on a branch in the phylogenetic tree formed by a HEV strain from German wild boar and from individuals with clinical manifestation of HEV infection during the last 4 years in the Netherlands, Sweden, Germany, and Bulgaria (Fig. ).
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.