Contributions
Abstract: PB2055
Type: Publication Only
Background
Hepatitis E virus (HEV) is a zoonosis mainly transmitted via oral-fecal route. Recent reports confirmed that HEV infection can be also transmitted through the transfusion of blood products in immunocompromised patients. HEV infection varies from a simple acute hepatitis with spontaneous recovery to acute liver failure and to chronic infection in immunosuppressed patients.
Aims
To describe two cases of acute HEV infection occurring in two patients with hematologic malignancies.
Methods
Adult patients with Non-Hodgkin lymphoma who developed HEV infection were selected from the institutional database.
Results
A 67-year-old man (pt 1) diagnosed with advanced stage peripheral T-cell lymphoma underwent multiple cycles of chemotherapy (6 CHOEP and 4 GDP) and autologous stem cell transplantation (ASCT) in partial remission. At transplantation the patient was negative for anti-HEV immunoglobulins. Three months after ASCT abrupt onset of diarrhea, weight loss, jaundice and rising in liver tests, prompted evaluation and hospital admission. Laboratory studies revealed AST 832 UI/L, ALT 1128 UI/L, and raised cholestatic liver enzymes (gGT 456 UI/L, total bilirubin 9.4 mg/dl, direct bilirubin 8,4 mg/dl). A 65-year-old man (pt 2) diagnosed with IV-B stage DLBCL started HyperCVAD. Viral serology before chemotherapy was negative. The first cycle of therapy was complicated by the increase of transaminases and cholestasis levels: AST 347 UI/L, ALT 365 UI/L, gGT 407 UI/L, total bilirubin 4.9 mg/dl, direct bilirubin 3.5 mg/dl. Both pts underwent RBCs and platelets transfusions. Hepatitis A, B, C, EBV and CMV infections were ruled out, autoimmunity tests were negative. Abdomen ultrasound did not reveal biliary ducts dilation, nor focal hepatic lesions. In pt 1, anti-HEV IgM and HEV RNA in the serum were positive, while pt 2 was positive only for HEV-RNA (1.3 x 106 genomes/ml) but tested negative for IgM and IgG. Diagnosis of acute HEV infection was confirmed. No immunosuppressive therapy was ongoing. Possible routes of infection were investigated: no contact with animals, no travels to endemic countries and no additional cases of HEV infections were reported at our unit during their hospitalization. Close monitoring of RNA-titer of the first patient showed progressive decrease of serum copies (36720 copies/ml à 1538 copies/ml); HEV-RNA was no longer quantifiable during serological controls after one month. Symptoms and liver function tests improved during admission with the sole supportive care. Excluding virus persistence, no antiviral treatment with ribavirin was started. To pt 2 was given ribavirine therapy, 600 mg for six months, for prolonged detection of serum HEV-RNA. Progressive reduction of HEV-RNA titer together with decrease of hepatic enzymes was observed with close monitoring, and clearance after four months from diagnosis was detected.
Conclusion
Acute hepatitis E case reports have increased in recent years in developed countries. Systematic HEV RNA screening of all blood donation is under consideration and already implemented in some Western countries as the risk and importance of transfusion-transmitted HEV infections by contaminated blood products is currently a controversial topic in transfusion medicine. A model estimates that receiving blood components from 13 donors carries a similar risk to one year of dietary exposure. The present report suggests that patients with hepatitis who have received blood products should be screened for HEV, especially if immunosuppressed.
Session topic: 31. Infectious diseases, supportive care
Keyword(s): chemotherapy, Hepatitis, Immunotherapy, lymphoma
Abstract: PB2055
Type: Publication Only
Background
Hepatitis E virus (HEV) is a zoonosis mainly transmitted via oral-fecal route. Recent reports confirmed that HEV infection can be also transmitted through the transfusion of blood products in immunocompromised patients. HEV infection varies from a simple acute hepatitis with spontaneous recovery to acute liver failure and to chronic infection in immunosuppressed patients.
Aims
To describe two cases of acute HEV infection occurring in two patients with hematologic malignancies.
Methods
Adult patients with Non-Hodgkin lymphoma who developed HEV infection were selected from the institutional database.
Results
A 67-year-old man (pt 1) diagnosed with advanced stage peripheral T-cell lymphoma underwent multiple cycles of chemotherapy (6 CHOEP and 4 GDP) and autologous stem cell transplantation (ASCT) in partial remission. At transplantation the patient was negative for anti-HEV immunoglobulins. Three months after ASCT abrupt onset of diarrhea, weight loss, jaundice and rising in liver tests, prompted evaluation and hospital admission. Laboratory studies revealed AST 832 UI/L, ALT 1128 UI/L, and raised cholestatic liver enzymes (gGT 456 UI/L, total bilirubin 9.4 mg/dl, direct bilirubin 8,4 mg/dl). A 65-year-old man (pt 2) diagnosed with IV-B stage DLBCL started HyperCVAD. Viral serology before chemotherapy was negative. The first cycle of therapy was complicated by the increase of transaminases and cholestasis levels: AST 347 UI/L, ALT 365 UI/L, gGT 407 UI/L, total bilirubin 4.9 mg/dl, direct bilirubin 3.5 mg/dl. Both pts underwent RBCs and platelets transfusions. Hepatitis A, B, C, EBV and CMV infections were ruled out, autoimmunity tests were negative. Abdomen ultrasound did not reveal biliary ducts dilation, nor focal hepatic lesions. In pt 1, anti-HEV IgM and HEV RNA in the serum were positive, while pt 2 was positive only for HEV-RNA (1.3 x 106 genomes/ml) but tested negative for IgM and IgG. Diagnosis of acute HEV infection was confirmed. No immunosuppressive therapy was ongoing. Possible routes of infection were investigated: no contact with animals, no travels to endemic countries and no additional cases of HEV infections were reported at our unit during their hospitalization. Close monitoring of RNA-titer of the first patient showed progressive decrease of serum copies (36720 copies/ml à 1538 copies/ml); HEV-RNA was no longer quantifiable during serological controls after one month. Symptoms and liver function tests improved during admission with the sole supportive care. Excluding virus persistence, no antiviral treatment with ribavirin was started. To pt 2 was given ribavirine therapy, 600 mg for six months, for prolonged detection of serum HEV-RNA. Progressive reduction of HEV-RNA titer together with decrease of hepatic enzymes was observed with close monitoring, and clearance after four months from diagnosis was detected.
Conclusion
Acute hepatitis E case reports have increased in recent years in developed countries. Systematic HEV RNA screening of all blood donation is under consideration and already implemented in some Western countries as the risk and importance of transfusion-transmitted HEV infections by contaminated blood products is currently a controversial topic in transfusion medicine. A model estimates that receiving blood components from 13 donors carries a similar risk to one year of dietary exposure. The present report suggests that patients with hepatitis who have received blood products should be screened for HEV, especially if immunosuppressed.
Session topic: 31. Infectious diseases, supportive care
Keyword(s): chemotherapy, Hepatitis, Immunotherapy, lymphoma