Li Weixiu, Du Lingyao, Ma Yuanji, Tang Hong
Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, Sichuan Province 610041, PR China.
Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
IDCases. 2024 Aug 27;37:e02069. doi: 10.1016/j.idcr.2024.e02069. eCollection 2024.
Acute hepatitis E virus (HEV) infection is a self-limiting disease, but HEV superinfection in patients with chronic hepatitis B virus (HBV) infection may lead to acute-on-chronic liver failure (ACLF) and significantly increase short-term mortality. Diagnosis and comprehensive management of these patients remain in a dilemma.
A 32-year-old man with chronic HBV infection for 8 years received entecavir due to abnormal liver function for 4 months. He was admitted for symptomatic hepatitis flare for nearly 2 weeks. Initial investigations did not reveal a cause other than HBV, but repeated tests showed a progressive increase in his anti-HEV IgM. His condition worsened rapidly. Mid-stage ACLF and spontaneous peritonitis were diagnosed. Entecavir and hepatoprotective drugs were continued. Ribavirin, ceftriaxone, and repeated artificial liver support system (ALSS) therapy were administered. His condition gradually improved and his liver function eventually returned to normal.
Repeated HEV screening is important for patients with chronic liver disease and symptomatic hepatitis flare. Negative anti-HEV IgM for the first time can easily lead clinicians to mistakenly rule out HEV infection. A progressive increase in anti-HEV IgM is one of the diagnostic criteria for HEV infection, which is not rare but deserves attention. Additionally, comprehensive management including ribavirin and ALSS would be effective therapies for patients who superinfect with HEV and develop ACLF.
急性戊型肝炎病毒（HEV）感染是一种自限性疾病，但慢性乙型肝炎病毒（HBV）感染患者发生HEV重叠感染可能导致慢加急性肝衰竭（ACLF），并显著增加短期死亡率。对这些患者的诊断和综合管理仍处于两难境地。
一名32岁男性，慢性HBV感染8年，因肝功能异常4个月接受恩替卡韦治疗。他因症状性肝炎发作入院近2周。初步检查未发现除HBV以外的病因，但重复检测显示其抗HEV IgM逐渐升高。他的病情迅速恶化。诊断为中期ACLF和自发性腹膜炎。继续使用恩替卡韦和保肝药物。给予利巴韦林、头孢曲松，并反复进行人工肝支持系统（ALSS）治疗。他的病情逐渐好转，肝功能最终恢复正常。
对于慢性肝病和症状性肝炎发作的患者，重复进行HEV筛查很重要。首次抗HEV IgM阴性容易导致临床医生错误地排除HEV感染。抗HEV IgM逐渐升高是HEV感染的诊断标准之一，这种情况并不罕见，但值得关注。此外，包括利巴韦林和ALSS在内的综合管理对于重叠感染HEV并发展为ACLF的患者将是有效的治疗方法。
