S5112 Hepatitis E Infection in a Patient With Lymphoma Masquerading as Drug-Induced Liver Injury

Introduction: Immunocompromised individuals are at high risk for Hepatitis E infection and progression to Cirrhosis and possibly death. Lack of inclusion in routine serology testing often leads to delayed diagnosis. Case Description/Methods: A 46-year-old man with a history of hypertension and type 2 diabetes mellitus was diagnosed with diffuse large B-cell lymphoma and underwent chemotherapy with Rituxan, Potaluzumab, and CHP (Cyclophosphamide, Doxorubicin, and Prednisone). Post-treatment, he experienced worsening liver function tests (LFTs) up to aspartate aminotransferase (AST) 514 U/L and alanine aminotransferase (ALT) 364 U/L. Basic work-up, including standard hepatitis panel, was negative, and the patient did not have an alcohol history. The differential diagnosis included, but was not limited to, drug-induced liver injury and autoimmune hepatitis. Treatment was started with prednisone, which led to marked improvement. However, LFTs worsened again (AST 462 U/L and ALT 654 U/L) following completion of the steroid course, so prednisone was restarted with a plan for a slow taper. Nevertheless, his LFTs continued to worsen (peaking at AST 379 U/L and ALT 1047 U/L), and common infectious etiologies, including EBV, HSV, CMV, and repeat hepatitis panel, came back negative. A liver biopsy reported a possible drug-induced liver injury. Due to continued worsening, further testing, including complete hepatitis serologies, was obtained. Hepatitis E testing returned positive with a polymerase chain reaction of 70,200 IU (negative less than 1800 IU/ml) and positive IgG and IgM antibodies. He was started on Ribavirin treatment for 12 weeks with normalization of his liver function studies. Discussion: Hepatitis E should be considered a potential risk factor for acute and chronic hepatitis, especially in high-risk populations. It is often misdiagnosed as a drug-induced liver injury. Lack of inclusion in routine testing and lack of available labs capable of testing can often lead to a delay in diagnosis and treatment.