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Acute fulminant hepatitis E virus genotype 3e infection: description of the first case in Europe

We thank Dr Bazarbachi and Dr Haffar for their interest in our article [1]. We agree with them that hepatitis E virus (HEV) infection represents an emerging problem in developed countries, which remains largely overlooked and deserves additional research efforts to better understand its peculiar aspects, especially in the industrialized setting. We appreciate their detailed comments about challenges in diagnosing liver cirrhosis (LC) in the context of acute fulminant hepatitis (AFH), with most of the radiological features overlapping for both conditions. In everyday clinical practice non-invasive imaging techniques play an important role in the diagnosis of LC [2], together with biochemical fi ndings [3]. In particular, several studies have shown a high accuracy (range 66 – 95%), and inter-observer agreement for computed tomography (CT) in the diagnosis of LC, suggesting that CT may be a useful diagnostic test in patients who have contraindications to biopsy [4,5]. Thus, although we acknowledge the possible limitations of the abovementioned studies (most of which do not include AFH patients), the reliability of this non-invasive imaging technique in the diagnosis of LC did support its use for this purpose in our patient. In addition, the clinical management and the diagnostic strategy we followed did consider the advanced age of the patient (79 years), and the coexistence of relevant comorbidities (including severe systemic atherosclerothic disease, previous aortic prosthesis placement, and coagulopathy). These defi ned a high risk for liver transplantation, an option that was accordingly not followed. Consequently, invasive procedures would not have changed our patient ’ s treatment plan, only adding potentially severe procedure-related side effects. Despite pancreatic head enlargement described on CT scan, acute pancreatitis was ruled out, since clinical signs such as abdominal pain were absent and biochemical parameters (amylase and lipase) were within normal limits. In conclusion, we agree with Dr Bazarbachi and Dr Hoffar on the observation that HEV infection should be considered and searched for in cases of acute hepatitis also in the western countries, since the disease is more prevalent than we thought and considering that it can follow a severe course and that possible treatments are available.