Case Discussion < Presentation of a Case >      A 30-year-old man was seen because of progressive yellowish skin and eyes for 4 days. He had been in good state of health until 7 days earlier before admission, when he began to have poor appetite, generalized malaise, and myalgia. Three days later, he noted that he had progressive jaundice and eyes became yellow. There was no abdominal pain, diarrhea, constipation or vomiting. Because of progressive yellowish skin and eyes and mild fever, he sought medical attention at our emergency department.      He was an engineer and had traveled to Mainland China about one month earlier prior to this admission. He had eaten crabs during his stay in Shanghai. He denied any systemic disease and glucose-6-phosphate dehydrogenase deficiency. There was no consumption of alcohol, tobacco and other medications. He had no history of animal contact or transfusion.      On physical examination, he had clear consciousness but was ill-looking. His height was 170 cm and weight was 70 kg. The temperature was 37.6°C, the pulse rate was 80 beats per minute and the respiratory rate was 16 breaths per minute. Blood pressure while in supine position was 100/70 mmHg. The skin was yellowish. There was no cyanosis, petechiae, purpura or pigmentation. His conjunctivae were pink, but the sclerae were icteric. The pupils were isocoric with prompt light reflexes. The neck was supple without lymphadenopathy, engorged jugular veins, palpable thyroid gland or carotid bruits. The chest wall expansion was symmetric and breath sounds were bilaterally clear. The heart beats were regular without audible murmur. The abdomen was soft. Bowel sounds were normoactive, and liver and spleen were impalpable. The liver span was estimated 10 cm at the right middle clavicle line. His extremities were freely movable without edema. < Laboratory data > 1. CBC WBC RBC HB HCT MCV MCHC PLT K/μL M/μL g/dL ％ fL g/dL K/μL 8.33 4.6 13.4 42.8 85.1 31.3 271 2. BCS+e-    ALB  TP T-Bil D-Bil AST ALT ALP  γ-GT g/dL g/dL mg/dL  mg/dL U/L U/L U/L U/L 3.7 6.9 12.66 10.90 1348 2068 498 172  UN CRE Na+ K+ Ca2+ Glucose LDH mg/dL mg/dL mmol/L mmol/L mmol/L mg/dL U/L 9.5 0.7 138 4.2 2.0 99 488  3. Urine analysis Appearance Sp. Gr pH Protein Glucose Ketone OB       g/dL  mg/dL     Y;C 1.03  7.0 30 - - -  Urobilirubin Bilirubin Nitrate WBC RBC Epi Cast           HPF   1.0 3+  - 0-1 0-1 3-5 - 4. Coagulation factor Prothrombin time PT cont INR Sec     16.7 11.1 1.5   5.Other tests IgM anti-HAV IgG anti-HAV IgM anti-HBc Anti-HBs HBs Ag - - - - - Anti-HCV IgM anti-HEV* (ELISA) IgG anti-HEV* (ELISA) Hanta* Leptospirosis* - > 3.0 ( > 0.474)  > 2.18 ( > 0.555) - -   EBV EA+EBNA1 IgA EBV-EA IgG EBV- VCA-IgA EBV- VCA-IgM ANA - 1 :10(-) 1 :10(-) 1 :10(-) -  HAV=hepatitis A virus ; HBc= hepatitis B core antigen ; HBs Ag =hepatitis B surface antigen ; HBVhepatitis B virus ; HCV= hepatitis C virus ; HEV = hepatitis E virus ; IgM = immunoglobulin M ; Ig G = immunoglobulin G ; ELISA=enzyme-linked immunosorbent assay; EBV = Epstein-Barr virus ; EBNA = Epstein-Barr nuclear antigen-1 ; EA = early antigen ; VCA = viral capsid antigen ; ANA = antinulclear antibody; * = available from Center for Disease Control and Prevention,Taiwan < Course and treatment > Acute viral hepatitis (hepatitis E) was diagnosed. Supportive management with hydration and glucose supplement was instituted. Abdominal sonography revealed parenchymal liver disease and mild splenomegaly. The levels of serum aminotransferases decreased gradually followed by decreases of serum bilirubin levels. He was discharged in a stable condition. < Discussion >       急性病毒性E型肝炎(acute hepatitis E)主要是經由腸道感染而引起肝臟發炎，受污染的食物和飲用水是其主要的傳染途徑，其流行病學特徵及臨床病程與A型肝炎類似，無任何跡象顯示E型肝炎病毒會導致慢性化。除了孕婦死亡率較高之外，其他人口感染E型肝炎則亦與A型肝炎類似。       E型肝炎病毒為一球型、無套膜、單股之RNA病毒。在急性感染期的初期，可在病患糞便中發現32至34 nm大小的病毒顆粒。流行於發展中國家，包括印度、尼泊爾、中國大陸、巴基斯坦及墨西哥等。主要感染年輕及中年人，且男性的感染率較高。目前台灣的E型肝炎病毒屬散發性病例。       急性病毒性E型肝炎主要經由糞口途徑傳染，潛伏期約15-60天，目前尚不清楚可傳染期多長。症狀無特異性，初期可能會有類似感冒症狀，包括食慾不振、噁心、輕微發燒、疲倦，之後出現黃疸(包括鞏膜及皮膚)，尿液顏色變深，出現黃疸後病患可能食慾會好轉，體溫也漸正常，病程持續約數天至數週，最後慢慢痊癒。       生化檢查可以發現肝功能指數(AST及ALT)明顯升高，血液膽紅素亦升高，利用聚合酵素鏈鎖反應(PCR)偵測E型肝炎病毒RNA及利用ELISA測定E型肝炎病毒抗體(IgM anti-HAV)呈陽性可以確定診斷。       急性病毒性E型肝炎的治療為支持性療法，包括：停止服食非必要藥物、充分休息、少量多餐、避免油膩及喝酒。目前並無疫苗可供預防，所以應該注意個人衛生習慣。另外，急性病毒性E型肝炎屬於第三類法定傳染病，發現疑似或確定病例時須於1週內通報當地衛生局(所)。 < References > Hepatitis E virus: epidemiology, diagnosis, pathology and prevention. Trop Gastroenterol. 2006;27(2):63-8. Review. Acute hepatitis E in pregnancy - study of 16 cases. JNMA J Nepal Med Assoc. 2006;45(161):182-5. Prevalence and risk factors for HEV infection in pregnant women. Med Sci Monit. 2006;12(1):CR36-39. Viral hepatitis during pregnancy. Int J Gynaecol Obstet. 2001;72(2):103-8. Detection of HEV antigen as a novel marker for the diagnosis of hepatitis E. J Med Virol. 2006;78(11):1441-8. 繼續教育考題 1. (B) 急性病毒性E型肝炎的傳染途徑？ A 血液 B 糞口 C 飛沫 D 性接觸 E 母體垂直感染 2. (A) 以下何者為E型肝炎病毒的特徵？ A 單股RNA B 雙股RNA C 單股DNA D 雙股DNA E 粒線體DNA 3. (A) 下列哪一個檢查結果可以確診為急性病毒性E型肝炎？ A IgM-anti-HEV陽性  B IgM-anti-HEV陰性 C IgG-anti-HEV陰性 D IgG-anti-HEV陽性 E 肝功能指數 (AST & ALT) 上升10倍以上 4. (C) 有關E型肝炎病毒的敘述下列何者正確？ A 會造成慢性肝炎 (chronic hepatitis) B 會成為帶原者 (carrier) C 可能會引起猛爆性肝炎 (fulminant hepatitis) D 會導致肝硬化 (cirrhosis) E 目前可以施打疫苗以避免感染 5. (C) 有關急性病毒性E型肝炎的治療下列何者為是？ A 抗生素  B 保肝丸  C 多休息  D 抗E型肝炎病毒之免疫球蛋白 E 干擾素 6. (D) 有關急性病毒性E型肝炎的敘述何者有誤？ A 流行於發展中國家   B 較易感染年輕人 C 男性感染率較高 D 孕婦感染死亡率較低  E 為第三類法定傳染病，須通報 答案解說 【B】HEV is transmitted via the fecal-oral route. Hepatitis E is a waterborne disease, and contaminated water or food supplies have been implicated in major outbreaks. 【A】Hepatitis E is caused by infection with the hepatitis E virus, a non-enveloped, positive-sense, single-stranded RNA virus. 【A】Diagnosis of hepatitis E is usually made by detection of specific IgM antibody, which disappears rapidly over a few months; IgG anti-HEV persists for at least a few years. 【E】Hepatitis E is a self-limited viral infection followed by recovery. Prolonged viremia or fecal shedding is unusual and chronic infection does not occur. Occasionally, a fulminant form of hepatitis develops, with overall patient population mortality rates ranging between 0.5% - 4.0%. At present, no commercially available vaccines exist for the prevention of hepatitis E. 【C】Hepatitis E is a viral disease, and antibiotics are of no value in the treatment of the infection. There is no hyperimmune E globulin available for pre- or post-exposure prophylaxis. HEV infections are usually self-limited, and hospitalization is generally not required. No available therapy is capable of altering the course of acute infection. 【D】Hepatitis E is an infectious viral disease with clinical and morphological features of acute hepatitis, clinically similar to other forms of acute viral hepatitis except in pregnant women, in whom the illness is particularly severe and has a high mortality rate.