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Opinion
Hepatitis E and chronic liver damage in apparently immunocompetent individuals: Now what?
Santiago Mirazo
Corresponding author
smirazo@fcien.edu.uy

Corresponding author at: Iguá 4225 PC 11400, Montevideo, Uruguay.
, Juan Arbiza
Sección Virología, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hepatitis E virus &#40;HEV&#41; has been recognized as the most common cause of acute viral hepatitis worldwide&#46; About 20 million infections occur per year&#44; resulting in around 70&#44;000 deaths <a class="elsevierStyleCrossRef" href="#bib0055">&#91;1&#93;</a>&#46; In developing regions HEV infection and related diseases are of significant health concern&#44; causing both sporadic cases and large outbreaks <a class="elsevierStyleCrossRefs" href="#bib0055">&#91;1&#44;2&#93;</a>&#46; HEV is classified into 8 genotypes &#40;HEV1&#8211;8&#41;&#44; of which HEV1-4 are capable to infect human&#46; HEV1 and HEV2 are anthroponotic pathogens and responsible for waterborne outbreaks in developing countries&#44; while HEV3 and HEV4 are zoonotic and infect swine <a class="elsevierStyleCrossRef" href="#bib0060">&#91;2&#93;</a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">There is substantial heterogeneity in the clinical presentation of HEV infection between developing and developed countries&#46; In developed regions&#44; sporadic locally acquired infections are most commonly caused by HEV3 <a class="elsevierStyleCrossRefs" href="#bib0055">&#91;1&#44;3&#93;</a>&#46; In this setting&#44; hepatitis E is mainly asymptomatic but a proportion of patients can course a self-limiting disease with typical symptoms of acute hepatitis&#44; e&#46;g&#46; malaise&#44; nausea and jaundice <a class="elsevierStyleCrossRef" href="#bib0055">&#91;1&#93;</a>&#46; In certain group of patients HEV infection may present as a fulminant disease or progressive fibrosis&#46; Pre-existent chronic liver disease is a major risk factor for developing acute-on-chronic liver failure <a class="elsevierStyleCrossRef" href="#bib0070">&#91;4&#93;</a>&#46; Chronic HEV infection can occur in immunocompromised individuals&#44; including transplant recipients and patients receiving chemotherapy for hematological malignancies&#46; A high proportion of solid-organ transplant recipients exposed to HEV will develop a chronic infection&#46; In immunocompromised patients infected with HEV3&#44; rapid progression of liver fibrosis to cirrhosis&#44; decompensation and death has been described <a class="elsevierStyleCrossRefs" href="#bib0055">&#91;1&#44;5&#93;</a>&#46; By contrast&#44; it is generally assumed that if an immunocompetent patient&#44; including a patient with cirrhosis&#44; is infected with HEV&#44; acute hepatitis E virus infection may occur&#44; but chronic infection will not progress&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite all these data&#44; clinical phenotype of sporadic and authocthonous cases of HEV infection still remain incompletely characterized&#44; and novel research poses challenges to understanding and appreciating the HEV threat to human health&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently&#44; Viera-Segura et al&#46; <a class="elsevierStyleCrossRef" href="#bib0080">&#91;6&#93;</a> provided additional evidences that contribute to further complicate things regarding the real burden and impact of HEV infection in less characterized epidemiological contexts&#44; such as Central America&#44; where both sporadic cases and waterborne outbreaks occurs <a class="elsevierStyleCrossRef" href="#bib0085">&#91;7&#93;</a>&#46; The work mainly focused on the study of HEV as a likely causative agent of viral hepatitis associated to liver damage in adult population from Mexico&#46; Beyond the main purpose of the research&#44; very interesting additional results were observed&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Mexico is generally regarded as hyperendemic for HEV infection&#44; though no outbreaks were reported since the 1980s&#44; when HEV2 had been described for the first time&#46; Even though many crucial epidemiological and molecular information is in general lacking &#40;only specific regions and population groups have been evaluated in Mexico&#41;&#44; available data suggest that HEV is indeed widely distributed among humans&#46; Furthermore&#44; domestic pigs are also highly exposed to HEV3 <a class="elsevierStyleCrossRef" href="#bib0085">&#91;7&#93;</a>&#46; Additionally&#44; it has been recently showed that HEV is a major cause of acute hepatitis in children&#44; with RNA detection rates as high as 17&#37; <a class="elsevierStyleCrossRef" href="#bib0090">&#91;8&#93;</a>&#46; Interestingly&#44; the only genotype detected in those samples belonged to HEV1&#44; previously reported in Central America&#46; Despite this&#44; hepatitis E is still underestimated&#44; and the burden of HEV infection in adult population is completely unknown&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Viera-Segura et al&#46; retrospectively investigated the role of HEV infection in adult patients with non-identified infectious etiological agent &#40;NIIEA&#41;&#46; Firstly&#44; results show that about 30&#37; of NIIEA -patients were infected with HEV3 and exhibited viremia&#46; This finding is interesting since clearly it shows that hepatitis E is still a neglected disease and HEV is not oftenly recognized as an important etiological agent of acute and&#47;or chronic hepatitis in Mexico&#46; Furthermore&#44; zoonotic transmission of HEV3 in adults&#44; by contrast to what seems to be occurring in children&#44; likely play a key role as a main cause of hepatitis in this setting&#46; On the other hand&#44; role of HEV2 as a causative genotype of hepatitis E appears to be negligible&#46; Further research is needed to corroborate all these data&#44; specially focused on the disease burden of HEV in selected groups of adults &#40;highly exposed individuals&#44; immunocompromised&#41; but also in child population&#44; where hepatitis E is not generally prevalent worldwide&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Secondly&#44; authors showed that none of the NIIEA-patients that had HEV RNA presented typical symptoms of acute hepatitis&#44; though they had an altered liver function&#46; At first sight this is not surprising given that most HEV infections are asymptomatic&#46; However&#44; many of these viremic patients exhibited advanced liver fibrosis&#46; Whether HEV infection played a role in the development of the chronic liver disease remains to be further investigated in these cases&#46; The natural history of hepatitis E in patients with chronic liver disease is not well understood and a superimposed acute infection may worse the pronostic and increase the mortality&#44; lead by a severe liver decompensation and the occurrence of severe extrahepatic manifestations <a class="elsevierStyleCrossRef" href="#bib0095">&#91;9&#93;</a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Liver damage associated to chronic HEV infection has been almost exclusively seen in immunocompromised individuals&#46; Just isolated cases were observed under an immunocompetent context&#44; but an occult history of immuosupression was often suggested <a class="elsevierStyleCrossRef" href="#bib0100">&#91;10&#93;</a>&#46; Interestingly&#44; Viera-Segura et al&#46; observed the all NIIEA-patients infected with HEV that exhibited liver fibrosis and evidences of advance liver damage&#44; were immunocompetent&#46; This finding is remarkable since&#44; even if HEV was not the exclusive etiologic agent of the liver disease&#44; hepatitis E might be probably playing a crucial &#40;unknown&#41; role in the pathogenesis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">But&#44; now what&#63; Altogether&#44; data suggest that the host&#8211;HEV interaction and infection dynamics could be much more complex than the initially assumed&#44; and probably certain severe clinical outcomes associated to hepatitis E may occur in an immunocompetent context&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Hepatitis E is still a cause of mortality and morbidity which negatively impacts the survival and prognosis of patients with chronic liver disease&#46; Recognition and diagnosis of HEV must be improved&#44; by increasing awareness and knowledge of basic and clinical aspects of the disease amongst clinicians&#46; Further research efforts should be done aimed to elucidate the clinical phenotype of hepatitis E among risked populations&#46; Prompt recognition of the infection&#44; supported by adequate molecular and serological testing and an early intervention of those groups of patients remains key to achieve effective management&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hepatitis E virus &#40;HEV&#41; is the most common cause of acute viral hepatitis worldwide&#44; accounting for 20 million infections per year and 70&#44;000 deaths&#46; In developed regions&#44; sporadic locally acquired infections are most commonly caused by HEV3&#44; and in this setting Hepatitis E is mainly asymptomatic&#46; However&#44; certain group of patients HEV infection may present as a fulminant disease or progressive fibrosis&#46; Chronic HEV infection can occur in immunocompromised individuals&#44; including transplant recipients&#46; A high proportion of solid-organ transplant recipients exposed to HEV are at risk of developing a chronic infection&#44; frequently associated to extrahepatic manifestations&#46; However&#44; clinical phenotype of sporadic cases of HEV infection is still poorly characterized&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A recent work&#44; focused on the retrospective study of HEV as a causative agent of viral hepatitis in adults form Mexico&#44; pose novel challenges to understanding the HEV threat to human health&#46; Main findings are brought into discussion herein&#44; in light of the current knowledge concerning viral pathogenesis and host&#8211;pathogen interaction&#46; The role of HEV infection in the development of chronic liver disease is also discussed&#46; Hepatitis E is a cause of mortality and morbidity which negatively impacts the prognosis of patients with chronic liver disease&#46; Recognition of HEV infection must be improved&#44; by increasing awareness and knowledge of the clinical phenotype of the disease&#46;</p></span>"
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ISSN: 16652681
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos