Question: A 36 year old American female is sent to see you because she was recently found to have a hepatitis of unknown etiology (ALT 200); she is asymptomatic. Hepatitis A, B and C were excluded, as well as autoimmune and metabolic diseases. She takes no medications. She asks whether she could have hepatitis E.
A. yes, HEV is common in the United States
B. yes, although HEV is extremely rare in the United States
C. no, since she did not travel to an endemic region
D. no, since she is not currently pregnant
Answer: Hepatitis E virus is transmitted similarly to hepatitis A virus; a large majority is from contaminated water or exposure to pigs. While it was once believed to be restricted to endemic areas like India, Bangladesh, Africa or South America, it is increasingly clear that HEV dwells in the United States as well. Rates of HEV infection are approximately 20% in the US overall (and 30% in those with pre-existing liver disease – Sherman et al. Emerging Infect Dis, 2009). The majority of people remain asymptomatic.
The diagnosis of HEV is difficult to make, in particular because one rarely considers it in the differential diagnosis. The IgM and IgG assays are not all that sensitive, and the treatment is supportive anyway. For this woman, HEV is still a possibility. I would reassure her that even if present, approach to management would not change, and therefore, sending for serologies may be unnecessary.