A 29-year-old woman, currently at 26 weeks of gestation, attends the emergency department with a five-day history of fatigue, fever, nausea and progressive yellow discolouration of her eyes.
She returned three weeks ago from a family visit to rural Bangladesh, where she frequently consumed locally prepared food and drinking water. Her antenatal course had previously been uncomplicated. She received hepatitis A vaccination before travelling.
On examination, she has scleral icterus and mild tenderness over the liver.
Investigations:
| Parameter | Result |
|---|---|
| Temperature | 38.3°C |
| Heart rate | 102/min |
| Total bilirubin | 86 µmol/L |
| ALT | 485 U/L |
| AST | 398 U/L |
| ALP | 275 U/L |
| GGT | 195 U/L |
| Albumin | 36 g/L |
| CRP | 118 mg/L |
Which infection is most likely responsible for this presentation?
A. Acute cytomegalovirus infection
B. Hepatitis B
C. Hepatitis E
D. Leptospirosis
E. Epstein–Barr virus infection
Correct Answer: C. Hepatitis E
Key MRCP clue: Pregnancy + recent travel to South Asia + acute hepatitis + jaundice = Think Hepatitis E.
Explanation
Hepatitis E is the most likely diagnosis because the patient has developed an acute hepatitis syndrome following travel to an endemic region.
The particularly important clue is pregnancy, because hepatitis E carries a disproportionately high risk of severe maternal disease during pregnancy, especially in the second and third trimesters.
According to WHO, mortality may reach approximately 20–25% among pregnant women infected during the third trimester in affected settings. who.intemro.who.int
Why does this presentation suggest Hepatitis E?
- Travel history: Bangladesh is situated in a region where hepatitis E is endemic.
- Transmission: Infection commonly occurs through drinking water contaminated with human faeces.
- Clinical features: Fever, malaise, nausea, right upper quadrant discomfort and jaundice are characteristic.
- Liver function: Raised bilirubin and transaminases indicate acute hepatocellular injury.
- Pregnancy: Significantly increases the risk of fulminant hepatitis and maternal mortality.
- Hepatitis A vaccination: Makes hepatitis A less likely, provided adequate immunity was achieved, but offers no protection against hepatitis E.
Confirmation of diagnosis
- Serum anti-HEV IgM antibodies suggest recent infection.
- HEV RNA detection by PCR confirms active infection.
- Check PT/INR, bilirubin, renal function and glucose to assess disease severity.
- Urgent obstetric and hepatology assessment is important because of the risk of acute liver failure and fetal complications. cdc.govarchive.cdc.gov
Hepatitis E – Essential MRCP Facts
| Feature | Important information |
|---|---|
| Virus | Hepatitis E virus \(HEV\) |
| Family | Hepeviridae |
| Genome | Positive-sense, single-stranded RNA |
| Transmission | Mainly faecal–oral |
| Principal source | Contaminated drinking water |
| Incubation period | Approximately 2–10 weeks; average 5–6 weeks |
| Endemic regions | South Asia, East Asia and sub-Saharan Africa |
| Clinical presentation | Acute hepatitis resembling hepatitis A |
| High-risk population | Pregnant women, particularly in later pregnancy |
| Major complication | Fulminant hepatic failure |
| Pregnancy mortality | May reach 20–25% in third-trimester infection in affected settings |
| Diagnosis | Anti-HEV IgM and HEV RNA PCR |
| Treatment | Primarily supportive |
| Chronic infection | Rare; mainly in immunosuppressed individuals |
| Vaccine | Hecolin \(HEV 239\), licensed in China and some other countries; not routinely available worldwide |
Important examination distinction
Hepatitis E is usually self-limiting in immunocompetent adults, but two circumstances deserve special attention:
- Pregnancy: Increased risk of fulminant hepatitis, maternal death and fetal loss, particularly with genotype 1 infection.
- Immunosuppression: HEV, especially genotype 3, can occasionally establish chronic infection, notably in solid-organ transplant recipients.
Remember that hepatitis E is not invariably an acute-only infection.
Summary for Quick Exam Revision
Hepatitis E is caused by a positive-sense, single-stranded RNA virus belonging to the Hepeviridae family. It is transmitted predominantly through the faecal–oral route, particularly by drinking water contaminated with human sewage. The infection is endemic in several regions, including South Asia and sub-Saharan Africa. The incubation period is approximately 2–10 weeks, averaging 5–6 weeks. Patients commonly develop fever, malaise, anorexia, nausea, abdominal discomfort and jaundice. The biochemical picture typically demonstrates elevated bilirubin and transaminases, reflecting acute hepatocellular injury. The most important MRCP association is hepatitis E infection during pregnancy. Pregnant women, especially during the second and third trimesters, have an increased risk of fulminant hepatic failure and fetal complications. Maternal mortality in third-trimester infection may reach approximately 20–25% in affected settings. Hepatitis A vaccination does not protect against hepatitis E. Diagnosis is established using anti-HEV IgM antibodies and/or HEV RNA PCR. Most immunocompetent patients recover spontaneously with supportive management, but pregnant patients require particularly careful monitoring. Chronic hepatitis E is uncommon but can occur in immunosuppressed patients, especially organ transplant recipients infected with genotype 3. A vaccine called Hecolin is licensed in China and certain other countries, although it is not part of routine worldwide immunisation programmes. Exam memory hook: Pregnant woman + South Asian travel + fever + jaundice = HEPATITIS E.