HEV is a single-stranded RNA virus that causes hepatitis E and can also affect other organs beyond the liver. It is transmitted via the fecal-oral route from contaminated water or undercooked meat. While HEV primarily affects the liver, it has also been associated with neurological, renal, hematological, musculoskeletal and cardiac effects. The most common extrahepatic manifestation is neurological disorders such as Guillain-Barré syndrome. Treatment of extrahepatic manifestations involves antiviral medication like ribavirin as well as steroids. Preventive measures include avoiding raw meat and untreated water from areas where HEV is prevalent.

1. HEV
BEYOND THE LIVER
By
Prof. Dr. Tarek Sheta
A. Professor of internal medicine
Mansoura Faculty of Medicine

2. HEV
 HEV is a single-stranded, non
enveloped, RNA virus.
 First isolated in 1983, by Russian
scientists investigating an outbreak in
Afghanistan.
Prof. Dr. TAREK SHETA

3. Prof. Dr. TAREK SHETA

4. Prof. Dr. TAREK SHETA

8. MODES OF TRANSMISSION
Prof. Dr. TAREK SHETA

11. Prof. Dr. TAREK SHETA

12. SEROLOGICAL DIAGNOSIS OF HEV
The period of viraemia may only be brief, so a negative PCR
does not necessarily exclude the diagnosis.
Prof. Dr. TAREK SHETA

13. HEV-
associated
extrahepatic
manifestations
Prof. Dr. TAREK SHETA

14. Pathophysiology of HEV-associated
extrahepatic manifestations
Not completely understood
but may be:
1) Direct cytopathic tissue
damage by extrahepatic
replication
2) Immunological
processes induced by an
overwhelming host
immune response.

15. EXTRAHEPATIC EFFECTS
OF HEV
 Neurological (commonest, occurring in
8% of infections).
 Nephrologic
 Haematologic
 Musculoskeletal
 Thyroid
 Heart
Prof. Dr. TAREK SHETA

16. HEV associated neurological
syndromes:
– Guillain−Barré syndrome
– Neuralgic amyotrophy
– Encephalitis
– Mononeuritis multiplex,
– Bell’s Palsy,
– peripheral neuropathy,
– mysotitis,
– vestibular neuritis
– Oculomotor palsy.
Prof. Dr. TAREK SHETA

18.  30% of
GBS
have
abnorm
al LFT’s
Prof. Dr. TAREK SHETA

19. Prof. Dr. TAREK SHETA

21. Meningo-encephalitis:
 HEV RNA in serum and CSF
 Ataxic component
 Poor outcome
Prof. Dr. TAREK SHETA

22. 2- RENAL MANIFESTATIONS
 Impairment of renal function at start of
HEV infection.
 Membrano-proliferative &
membranous glomerulonephritis
during acute & chronic infection.
 Cryoglobulinemia that disappears
after HEV clearance.
 Regression of nephrotic syndrome
after HEV clearance.
Prof. Dr. TAREK SHETA

23. OTHER EXTRAHEPATIC
MANIFESTATIONS
. Hemolytic anemia
Henoch-Schonlein Purpura
Prof. Dr. TAREK SHETA

25. TREATMENT OF EXTRAHEPATIC
MANIFESTATIONS
 No drug has been approved for the
treatment of hepatitis E extrahepatic
manifestations
 several reports demonstrating good
antiviral efficacy of ribavirin in patients
with acute or chronic HEV infection
 GBS were treated with ribavirin or
ribavirin and intravenous
immunoglobulin
Prof. Dr. TAREK SHETA

26.  In addition to ribavirin, steroids have
been shown to be effective in patients
with extrahepatic manifestations
Prof. Dr. TAREK SHETA

27. Prof. Dr. TAREK SHETA

28. Prevention of extrahepaic
HEV- associated infections
 The only way is to prevent acquiring HEV
infection.
 Thus, consumption of raw swine meat and
consumption of unboiled water in tropical
countries should be avoided.
 Testing of blood products for HEV would avoid
blood-borne HEV-transmission. However, this
cost-intensive process is still under debate.
 Excellent vaccines have been developed, but
marketed only in China, which could be used in
populations at risk

29.  HEV infection is more prevalent worldwide
than hitherto recognised and is associated
with significant morbidity and mortality.
 Excess mortality in pregnant women.
 Seroprevalence of IgG anti-HEV in blood
donors may reach 50% in some geographical
areas.
Prof. Dr. TAREK SHETA

30.  Hepatitis E in developed countries is a
zoonosis transmitted by raw or undercooked
pork or game meat and shellfish.
 Pre-existing liver disease may cause hepatic
decompensation.
Prof. Dr. TAREK SHETA

31. CONCLUSIONS
 Hepatologists should be aware of the
possibility that acute or chronically HEV-
infected patients could develop extrahepatic
manifestations.
 Neurologists, nephrologists, rheumatologists
should consider HEV infection as a potential
differential diagnosis when observing one of
the diseases described.
Prof. Dr. TAREK SHETA