Older men with unexplained hepatitis

A 59-year-old Caucasian man presented with painless jaundice for 6 weeks. He drank 70 units of alcohol per week. Examination revealed jaundice, spider angiomata and a 3 cm firm hepatomegaly. Initial bloods: bilirubin 152 µmol/L, alanine aminotransferase 1484 IU/L, alkaline phosphatase 130 IU/L, γ-glutamyl-transpeptidase 1224 IU/L and International Normalised Ratio 1.1. A standard liver screen was normal, and an abdominal ultrasound/CT scan suggested cirrhosis, confirmed by liver biopsy on day 5. Hepatitis E virus (HEV) serology on day 6 indicated acute infection. He developed severe hepatic decompensation characterised by worsening jaundice, ascites and variceal bleeding. On day 33 ribavirin 600 mg was initiated though discontinued after 2 weeks on receipt of a negative HEV RNA. At the last follow-up he had recovered, and remains abstinent from alcohol. We describe a case of autochthonously (locally) acquired HEV infection with life-threatening hepatic decompensation in the presence of undiagnosed alcohol-related cirrhosis.