Coinfection of hepatitis A virus genotype IA and IIIA complicated with autoimmune hemolytic anemia, prolonged cholestasis, and false-positive immunoglobulin M anti-hepatitis E virus: a case report

Abstract

A 37-year-old male presented with fever and jaundice was diagnosed as hepatitis A complicated with progressive cholestasis and severe autoimmune hemolytic anemia. He was treated with high-dose prednisolone (1.5 mg/kg), and eventually recovered. His initial serum contained genotype IA hepatitis A virus (HAV), which was subsequently replaced by genotype IIIA HAV. Moreover, at the time of development of hemolytic anemia, he became positive for immunoglobulin M (IgM) anti-hepatitis E virus (HEV). We detected HAV antigens in the liver biopsy specimen, while we detected neither HEV antigen in the liver nor HEV RNA in his serum. This is the first report of hepatitis A coinfected with two different genotypes manifesting with autoimmune hemolytic anemia, prolonged cholestasis, and false-positive IgM anti-HEV.

Figure 1

(A) Peripheral blood smear showing marked polychromasia and anisocytosis (Wright-Giemsa stain, ×1,000). (B) Photomicrographs of a bone marrow biopsy section showing increased erythropoiesis [hematoxylin and eosin stain (H&E), ×400].

Figure 2

The liver biopsy specimen exhibited hepatocellular and canalicular cholestasis, hepatocyte ballooning, and lobular spotty necrosis, consistent with cholestatic hepatitis. Extramedullary hematopoiesis was also seen (arrow; H&E, ×200).

Figure 3

Immunohistochemical staining of the liver biopsy specimen. Strong cytoplasmic staining for hepatitis A virus antigen was noted in our case (A), whereas staining was absent in a case of chronic hepatitis B (B) as a negative control (A and B, ×400).