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.