Case Presentation: A 54-year-old man presented with one week of fatigue, jaundice, pruritus, dark urine, and pale stools. He denied fever or chills but endorsed a ten pound weight loss over one month. He reported no history of liver disease, intravenous drug use, new sexual partners, recent travel, or blood transfusions.
His past medical history included prostate cancer s/p total prostatectomy and radiation, a 38-pack-year smoking history, and ongoing alcohol use (14 beers/night for 10 years). Exam revealed scleral icterus, jaundice, mild right upper quadrant tenderness, and intact mental status. Initial labs were notable for WBC 5,500/uL, INR 1.0, alanine aminotransferase 6005 U/L, aspartate aminotransferase 4615 U/L, total bilirubin 7.1 mg/dL, direct bilirubin 5.4 mg/dL, negative hepatitis A/B/C serologies, serum ferritin 29,756 mg/dL, and serum acetaminophen <5 ug/mL. Ultrasound showed a contracted gallbladder with normal liver echo texture. HFE C282Y mutation was negative.
During his hospitalization, liver function tests slowly improved, but the diagnosis remained unclear. The patient’s wife then revealed that the patient was an avid deer hunter and consumed large quantities of venison. Consequently, hepatitis E serologies were checked and returned positive for hepatitis E immunoglobulin M (IgM). Following discharge, serum F-actin and anti-smooth muscle IgG both returned weakly positive. Two months later, serologies were positive for hepatitis E IgG, liver function had normalized, and the patient was asymptomatic. The positive F-actin and anti-smooth muscle IgG were felt to be false positives in reaction to acute viral hepatitis.
Discussion: Hospitalists frequently encounter patients with acutely abnormal liver function. Typical initial workup includes obtaining a detailed history, serum acetaminophen level, hepatitis A/B/C serologies, and a right upper quadrant ultrasound. However, hepatitis E is often not considered despite being a common cause of acute hepatitis worldwide.
While most suffer from a self-limited infection acquired through consumption of contaminated water or food (commonly venison, swine, or shellfish), prognosis and route of transmission vary by viral genotype and immune status of the patient. In particular, pregnant women and immunosuppressed patients have a much higher risk of developing acute hepatic failure and/or chronic hepatitis. Therefore, consideration of hepatitis E infection is vital in the management of patients who present with liver dysfunction of unknown cause and risk factors such as immune compromise, exposure to endemic regions, or recent consumption of commonly contaminated food.
Conclusions: Hepatitis E is a frequent cause of acute hepatitis globally but remains seriously underdiagnosed. Consideration of this etiology is critical for accurate diagnosis and treatment in the setting of abnormal liver function and the presence of immune-suppression, travel to endemic regions, or consumption of commonly contaminated foods.
To cite this abstract:Shah, N; Pascoe, J. OH DEER! A CASE OF ACUTE HEPATITIS E SECONDARY TO VENISON CONSUMPTION. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 974. https://www.shmabstracts.com/abstract/oh-deer-a-case-of-acute-hepatitis-e-secondary-to-venison-consumption/. Accessed November 17, 2019.