Takakusagi Satoshi, Takagi Hitoshi, Yamazaki Yuichi, Kosone Takashi, Nagashima Shigeo, Takahashi Masaharu, Murata Kazumoto, Okamoto Hiroaki
Department of Gastroenterology and Hepatology, Kusunoki Hospital, 607-22 Fujioka, Fujioka, Gunma, 375-0024, Japan.
Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
Clin J Gastroenterol. 2023 Apr;16(2):206-215. doi: 10.1007/s12328-022-01733-2. Epub 2022 Nov 20.
A woman in her late 70 s was diagnosed with liver injury at a health examination. Despite treatment with ursodeoxycholic acid at a nearby hospital, her transaminase levels elevated in two peaks. She was transferred to our hospital 77 days after the health examination. She weighed 42 kg and had a low body mass index of 19.8 kg/m. Viral markers, including immunoglobulin A (IgA) against hepatitis E virus (anti-HEV IgA), were negative. Drug-induced liver injury was negligible. We suspected autoimmune hepatitis because of the patient's female gender and positive antinuclear antibody. However, prednisolone and azathioprine failed to completely improve her hepatitis. On day 643, anti-HEV IgA was re-evaluated and found to be positive. She was diagnosed with autochthonous chronic hepatitis E because the virus strains in the preserved serum on day 77 and the serum on day 643 had identical nucleotide sequences (genotype 3a). Following prednisolone and azathioprine discontinuation, ribavirin (RBV) was administered for 3 months. HEV RNA disappeared and remained negative for more than 6 months after the cessation of RBV. The HEV RNA titer of 6.2 log copies/mL on day 77 was unusually high 2.5 months after the onset, suggesting that hepatitis E had already been chronic before immunosuppressive treatment for possible autoimmune hepatitis. After getting married at 23 years old, she had been a housewife and had no comorbidities that might deteriorate her immunity. Chronicity should be kept in mind when encountering HEV infection in elderly and underweight patients.
一名70多岁的女性在健康检查时被诊断出肝损伤。尽管在附近医院接受了熊去氧胆酸治疗，她的转氨酶水平仍出现了两次峰值升高。健康检查77天后，她被转到我院。她体重42公斤，体重指数低，为19.8kg/m。包括抗戊型肝炎病毒免疫球蛋白A（抗HEV IgA）在内的病毒标志物均为阴性。药物性肝损伤可忽略不计。由于患者为女性且抗核抗体阳性，我们怀疑为自身免疫性肝炎。然而，泼尼松龙和硫唑嘌呤未能完全改善她的肝炎病情。在第643天，重新检测抗HEV IgA，结果呈阳性。她被诊断为散发性慢性戊型肝炎，因为第77天保存血清和第643天血清中的病毒株具有相同的核苷酸序列（3a基因型）。停用泼尼松龙和硫唑嘌呤后，给予利巴韦林（RBV）治疗3个月。RBV停药后，HEV RNA消失并在6个多月内一直保持阴性。发病2.5个月后，第77天的HEV RNA滴度为6.2 log拷贝/mL，异常高，这表明在针对可能的自身免疫性肝炎进行免疫抑制治疗之前，戊型肝炎就已经呈慢性。她23岁结婚后一直是家庭主妇，没有可能使免疫力下降的合并症。在老年和体重过轻的患者中遇到戊型肝炎病毒感染时，应考虑到慢性感染的情况。
