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CASE OF THE MONTH - December 2019

Unexplained hepatitis in a returning traveller, a case report on Hepatitis E

Dr A Engelbrecht MB ChB, Dip HIV Man (SA)
Dr MY Brinkhuis MB ChB
Dr JL Pretorius MB ChB, Mmed (internal Medicine and Infectious Diseases), FCP SA
Department of Internal Medicine, Worcester Hospital

Case Presentation
Our patient was a 61-year-old female from South Korea. She presented with a hepatitis, giving a 4-day history of fever, rigors, nausea, vomiting, myalgia and headache. She recently travelled to the Philippines, South Korea and Kenya before arriving in South Africa. She attended a work-related conference in Manilla in the Philippines 3 weeks prior to presentation, during which time she stayed in a conference hotel. She denied any sexual activity, alcohol use, tobacco, or illicit drugs. She denied taking any over the counter or prescribed medicines or herbal supplements. She only ate the hotel food and drank bottled water. She returned to South Korea for 3 days before leaving for Kenya. She arrived in Nairobi 1 week prior to presentation. She only stayed in the capital city with no travel to rural areas. Again, only eating hotel food with no specific insect or rodent exposure. She received no previous blood transfusions and had no personal or family history of liver disease.

Admission vital signs were in the normal range. On examination she was apyrexial, not jaundiced, had no eschars or rashes, and had mild epigastric tenderness with no organomegaly and no clinical features of liver failure. After 2 days in a general medical ward she became icteric. Her blood results are summarized in Table 1.

Day of Admission
Day 1 Day 4 Day 6 Day 8
TB 31 99 117 97
CB 25 92 105 95
ALT 1280 2389 1954 873
AST 1099 3100 1242 219
ALP 395 408 369 292
GGT 922 1004 837 603
LDH 615 992 468 210
INR 0.99 1.15 1.02 0.9

Table 1
(Abbreviations for Table 1 - TB: Total Bilirubin, CB: Conjugated Bilirubin, ALT: Alanine aminotransferase, AST: Aspartate aminotransferase, ALP: Alkaline phosphatase, GGT: Gamma-glutamyl transpeptidase, LDH: Lactate dehydrogenase, INR: International Normalised Ratio)

Further testing revealed negative HIV ELISA, negative Hepatitis A IgM, negative Hepatitis B surface antigen (HepBsAg) and surface antibody (HepBsAb), negative Hepatitis C IgG, and negative malaria thin and thick smear. An ultrasound of the liver was performed and showed normal liver structure and vasculature with a normal biliary system and no lymphadenopathy.