Hepatitis E Virus Infection Caused Elevation of Alanine Aminotransferase Levels in a Patient with Chronic Hepatitis B and Choledocholithiasis

Abstract

Hepatitis E virus (HEV) genotypes 3 and 4 are zoonotic strains that are primarily transmitted through the consumption of undercooked pork or game meat. They also cause asymptomatic infections, acute hepatitis, acute-on-chronic liver failure, chronic hepatitis, and extrahepatic manifestations. Here, we report a man in his 80s who had chronic hepatitis B, took entecavir for it, and presented with higher levels of alanine aminotransferase (ALT) and jaundice. An abdominal computed tomography scan revealed choledocholithiasis with cholecystolithiasis. Although endoscopic papillary balloon dilatation was performed for the removal of a common bile duct stone, the abnormal liver function tests, including jaundice, were prolonged. After other viral hepatitis and other causes of the liver injury were ruled out, as his serum was positive for immunoglobulin A anti-HEV and HEV genotype 3b RNA, we diagnosed him as having acute hepatitis E. In this case, with chronic hepatitis B and a common bile duct stone, the prolonged abnormal results for the liver function tests seemed to be caused by HEV infection. In conclusion, in cases with high ALT levels after removing choledocholithiasis, other factors, including HEV infection, should be considered to determine the cause of abnormal liver function test results. The further examination of hepatitis D virus infection and high ALT levels may be needed in HBV-infected individuals.

Keywords: HBV; HEV; common bile duct stones; prolonged jaundice.

Figure 1

Computed tomography images on admission to our hospital. (a) Cholelithiasis was observed in the gallbladder. (b) Choledocholithiasis was observed in the common bile duct.

Figure 2

Endoscopic papillary balloon dilatation (EPBD) for a bile duct stone in this case. (a) EPBD for the management of the common bile duct stone. The sky-blue-colored tube is a prophylactic pancreatic stent. (b) Cholangiogram showing a 5 mm stone in the common bile duct.

Figure 3

Clinical course of this case. ALT, alanine aminotransferase; ALP, alkaline phosphatase; T. Bil, total bilirubin; HEV, hepatitis E virus; Ig, immunoglobulin. IgG anti-HEV, IgM anti-HEV, and IgA anti-HEV levels were measured using an enzyme-linked immunosorbent assay (ELISA), and HEV RNA was measured via real-time RT-PCR according to previously described methods [9,10,11,12,13].