Neurologic complications of acute hepatitis E virus infection

Abstract

ObjectiveTo assess the prevalence and clinical features of neurologic involvement in patients with acute hepatitis E virus (HEV) infection in Southern Switzerland.MethodsAmong 1,940 consecutive patients investigated for acute hepatitis E, we identified 141 cases of acute of HEV infection (anti-HEV immunoglobulin M and immunoglobulin G both reactive and/or HEV RNA positive) between June 2014 and September 2017. Neurologic cases were followed up for 6 months. We compared patients with and without neurologic symptoms.ResultsNeurologic symptoms occurred in 43 acute HEV cases (30.4%) and consisted of neuralgic amyotrophy (NA, n = 15, 10.6%) and myalgia (n = 28, 19.8%). All NA cases were immunocompetent. Men had higher odds (OR = 5.2, CI 1.12–24.0, p = 0.03) of developing NA after infection with HEV, and in 3 couples simultaneously infected with HEV, only men developed NA. Bilateral involvement of NA was predominant (2:1) and occurred only in men. Seven NA cases were viremic (all genotype 3), but HEV was undetectable in their CSF. In the acute phase of NA, 9 patients were treated with intravenous immunoglobulin and 4 with prednisone, reporting no side effects and improvement in pain and strength. Myalgia occurred both without (n = 16) or with (n = 12) concomitant elevated serum creatinine kinase. Seven cases with myalgia in the shoulder girdle did not have muscle weakness (“forme fruste” of NA).ConclusionsNeurologic symptoms occurred in one-third of acute HEV infections and consisted of NA and myalgia. NA seems to occur more frequently in men infected by HEV and has a predominant (but not exclusive) bilateral involvement.

Neuralgic amyotrophy and hepatitis E infection: 6 prospective case reports

“…Previous authors stated that HEV-associated NA cases were more likely to be men, middle-aged, have bilateral involvement of brachial plexus (80% vs 8.6%), 17 and a particularly high prevalence of phrenic nerve involvement was found by Van Eijk (24.5% vs 3.5%, p=0.01), 18 along with Scanvion (18.0% vs 6.6%, p=0.028) compared with global population of NA. 19 In our case series, 5 out of 6 patients were male, which was consistent with a recent study that suggested a higher likelihood of HEV-associated NA in men. 19 Indeed, Ripellino et al, in their study of 141 acute HEV infection, found out that men had higher odds (OR =5.2, CI 1.12 to 24.0, p=0.03) of developing NA after infection with HEV.…”

“…An interesting fact in this study was that three couples were simultaneously infected with HEV, in which only the men developed NA. 19 In our case series, 3/6 patients had anterior interosseous nerve paresis, which might also induce a severe disability (in writing and fine motor control activities). This particular pattern may be overlooked and was not diagnosed in our patients before EDX was performed.…”

“…This is consistent with larger studies, highlighting the interest in early testing for HEV in case of NA. 19 The main limitations of our study include reporting cases seen in a tertiary centre, which might be more severe than usual HEV-associated NA, and not including functional criteria in the assessment of our patients. This was not the goal of our work but limitation of activity, evaluated by functional criteria should be investigated in further studies.…”

Advances in Hepatitis E Virus Biology and Pathogenesis

“…Neurological pain is more frequently observed in immunocompetent patients over 50 years old [ 179 ]. In a recent clinical study, among 141 cases of acute HEV infection in Southern Switzerland, 43 (30.4%) had neurological symptoms within six months [ 180 ]. In the 141 cases, 15 (10.6%) showed neuralgic amyotrophy, and 28 (19.8%) presented myalgia.…”

Control of Raw Pork Liver Sausage Production Can Reduce the Prevalence of HEV Infection

“…A previous observational study carried out in Southern Switzerland [ 14 ] identified 141 acute cases of HEV, of whom approximately 30% complained of neurological symptoms. Almost all these patients reported consumption of raw pork meat products in the month preceding the appearance of symptoms.…”