Introduction Chronic hepatitis E virus (HEV) infection, with rapidly progressive cirrhosis, has recently been documented in immunosuppressed solid organ transplant recipients. In this setting HEV viral clearance can be achieved by either reducing the dose of immunosuppressive agents or by the use of pegylated interferon and/or ribavarin. Chronic HEV infection has also been observed in patients co-infected with human immunodeficiency virus (HIV).1 Acute and chronic HEV is sometimes associated with sensory/motor neuropathy.
Aim To describe the clinical and laboratory features of HEV/HIV co-infection, and response to antiviral therapy.
Method A 48-year-old bisexual male was found to be infected with HIV-1 in 2001. In 2003 he was treated for military tuberculosis. Following this he developed a painful, progressive sensory peripheral neuropathy affecting the lower limbs. In 2007 he was noted to have abnormal LFTs. After loss to follow-up, repeat LFTs remained abnormal and a liver biopsy (2009) showed established cirrhosis with active inflammation. Chronic HEV infection was documented with persisting viraemia in serum and stool over a 3 year period (Jan 2007–Jan 2010). HEV was also recovered from his cerebrospinal fluid. He remained antiretroviral naïve until January 2007, when he commenced on tenofovir/emtricitabine and lopinavir/ritonavir. Although transiently switched to efavirenz he settled on his current regimen of abacavir/lamivudine and lopinavir/ritonavir in June 2007. His HIV viral load became undetectable but his CD4 count remained low (100–170 /mm3).
Results In July 2009 he was treated with Pegasys 135 microg/week. His LFTs normalised and his HEV viral load declined. At 6 months he achieved HEV clearance from his serum, but HEV was still detectable in stool. Ribavarin 1 g/day was added in for a further 3 months. HEV viral clearance was achieved from serum and stool. During treatment, neurological symptoms improved and, by the time viral clearance was achieved, they were abolished. He remains HEV PCR negative 3 months after completion of therapy.
Conclusion Chronic HEV infection can occur in the context of HIV and can be associated with neurological symptoms. HEV viral clearance can be achieved by combination therapy with Pegasys/ribavarin, with normalisation of LFT's and resolution of neurological symptoms. The mechanism of neurological damage in HEV infection is uncertain.
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