S5959 Two Sides of the Same Coin: Contrasting Presentations and Outcomes of Hepatitis E Virus Infection in a Transplant Recipient and an Immunocompetent Host

Introduction: Hepatitis E virus (HEV) is a non-enveloped RNA virus known to cause self-limited hepatitis in immunocompetent individuals but may lead to chronic infection in immunocompromised hosts. In rare cases, HEV can cause acute liver failure (ALF). We present 2 contrasting cases that illustrate the clinical spectrum of HEV infection and underscore the importance of early recognition and tailored management. Case Description/Methods: Case 1 shows acute liver failure in an immunocompetent host. A 67-year-old man with diabetes and coronary artery disease presented with jaundice and hepatic encephalopathy. Labs revealed aspartate aminotransferase (AST) 9,813 U/L, alanine aminotransferase (ALT) 7,057 U/L, bilirubin 16.8 mg/dL, international normalized ratio 3.5, and ammonia 109 µmol/L. HEV IgM, IgG, and RNA (4.56 million IU/mL) were positive. Liver biopsy showed severe hepatitis with bridging necrosis. Despite intensive care until-level care, he deteriorated rapidly and died 5 days later. Autopsy confirmed fulminant hepatic necrosis due to HEV. Case 2 demonstrates chronic HEV in a liver transplant recipient. A 47-year-old man with nonalcoholic steatohepatitis cirrhosis underwent liver transplantation. Three months later, he developed elevated liver enzymes (AST 133 U/L, ALT 573 U/L). Biopsies showed mild hepatitis without rejection. HEV RNA was positive (5.5 million IU/mL). He was treated with ribavirin 400 mg BID and adjustments in immunosuppression. After 12 weeks, liver enzymes normalized, and HEV RNA became undetectable. He remained well 3-months post-treatment. Discussion: These cases highlight the divergent outcomes of HEV based on host immune status. The immunocompetent patient developed fulminant hepatitis and died, despite having a similar viral load to the transplant recipient who recovered with antiviral therapy. In immunocompromised patients, HEV may present subtly but progress to chronicity. Early HEV testing should be considered in patients with unexplained hepatitis, particularly those with recent transplantation or systemic stress. Prompt diagnosis and appropriate therapy can significantly alter outcomes.