Hepatitis E
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Introduction

Electron microscope image of hepatitis E virions
Electron microscope image of hepatitis E virions

Hepatits E is an inflammation of the liver caused by the hepatitis E virus (HEV). Hepatitis E is clinically similar to Hepatitis A. Many cases are asymptomatic.

There are an estimated 20 million cases of HEV each year, although only about 3 million of these are thought to be symptomatic. HEV is estimated to cause about 44 000 deaths each year.

Infection is usually self-limiting and lasts between 2-6 weeks before being cleared. Very rarely acute liver failure can develop – which can be fatal. Pregnancy – particularly in the third trimester – is associated with much higher mortality – up to 25%.

It is transmitted via the faecal-oral route – most commonly in contaminated water. HEV is found worldwide but is most common in East and South Asia.

A vaccine against hepatitis E exists in China but has not been licensed elsewhere – as of June 2022.

Aetiology

  • Waterborne similar to hep A (shellfish and water melons!). 30% of dogs, rodents and pigs carry the virus – usually without causing any disease
  • Common in regions with poor sanitation. In these areas – contamination of water sources may occur and can infect hundreds or thousands of individuals at once.
  • In other regions – occasional cases can occur when cases are caught from animals
  • There are 4 genotypes – types 1 and 2 are typically waterborne and types 3 and 4 typically circulate in animal populations

Presentation
Very similar to that of any other acute hepatitis:

  • Many patients are asymptomatic. They may never know they have had the disease
  • Very rarely it can be life-threatening
  • May be a prodromal phase
  • Jaundice, malaise, abdominal pain, nausea & fever – usually lasting around 2 weeks
  • Incubation period is 2-10 weeks (Average of 5-6 weeks)
  • Symptoms and cases are generally much more mild in children

Other Factors:

  • Generally does not cause chronic disease – but is is possible – usually only seen in iummunocompromised patients
  • 25% mortality in pregnancy. Often baby will also die. This does not happen with hep A. 
  • During an acute infection, IgM antibodies (anti-HEV) are present.
  • There is no active or passive immunity to hepatitis E

Diagnosis

  • HEV IgM antibodies can be detected in serum
  • HEV PCR can also be performed
  • Usually testing is only performed once hepatitis A has been excluded

Management

  • There is no specific management
  • Disease is usually self-limiting
  • Immunosupressed patients with chronic hepatitis E may benefit from Ribavarin (an antiviral). Interferon may also be used.

Prevention

Prevention efforts focus around improving sanitation in areas that are high-risk or have an history of outbreaks.

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
  • Hepatitis E – WHO

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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