Discussion
Differential diagnosis in patient with elevated aminotransferase undergoing chemotherapy requires the consideration of various causes. The diagnosis of HEV infection is often difficult, especially because drug toxicity-related causes must be excluded, and symptoms vary considerably from patient to patient. In the present case, a detailed interview led us to conclude that the pigs were likely reservoirs.
Because of the great diversity in the immune status of patients undergoing chemotherapy, as in this case, serodiagnosis alone may not accurately detect HEV infections. Therefore, it should be performed that the HEV polymerase chain reaction simultaneously with HEV serodiagnosis if HEV infection is suspected in immunosuppressed patients under special conditions.
In general, treatment of acute HEV infection is often supportive; however, some patients may require discontinuation of immunosuppressive drugs or ribavirin treatment. This includes cases in which prednisolone is being administered, as in the present case (2).
Previous reports have shown that ribavirin used either alone or in combination with peginterferon has been effective in the treatment of chronic HEV in patients with hematologic diseases (3). However, there are no data on the recommended duration of these treatments, especially the use of ribavirin. It has been shown in the past that ribavirin therapy may be necessary for high-risk patients, such as those undergoing chemotherapy for gynecologic cancer (3, 4)
Several reports have shown that immunosuppressed patients are at a high risk of HEV infection, which may have serious clinical consequences owing to prolonged HEV autoproliferation. The patient was treated with anti-CD20 antibodies and cyclophosphamide for the hematologic tumor. The chronic course of HEV infection may have been precipitated by immunosuppression. The first step in the treatment of patients with chronic infections is the reduction or cessation of immunosuppressive drugs (5) In this case, the patient was started on ribavirin therapy after adjusting the dosage of chemotherapy drugs. The patient was able to safely complete the treatment, and complete remission was achieved.
In conclusion, patients with unexplained acute or chronic hepatitis during immunosuppression should be considered for possible HEV infection and should be tested for infection. In addition, patients receiving immunosuppressive therapy should be carefully monitored for a chronic course of HEV.