European Journal of Internal Medicine 26 (2015) 348–350
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Original Article
Evidence for the presence of autochthonous (locally acquired) cases of acute hepatitis E virus infections in Italy since the 80s Tommaso Stroffolini a, Maria Rapicetta b,⁎, Paola Chionne b, Rozenn Esvan a, Elisabetta Madonna b, Flavia Lombardo c, Fabrizio Toccaceli a, Giulio Pisani d, Annarita Ciccaglione b, Flavia Bortolotti e a
Department of Infectious and Tropical Diseases, Policlinico Umberto I, Rome, Italy Viral Hepatitis Unit, Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy National Center for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy d Center for Immunobiological Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy e Department of Experimental and Clinical Medicine, University of Padua, Italy b c
a r t i c l e
i n f o
Article history: Received 21 January 2015 Received in revised form 18 March 2015 Accepted 29 March 2015 Available online 14 April 2015 Keywords: Hepatitis E HEV HCV Acute infection Epidemiology Italy
a b s t r a c t Background: Autochthonous (locally acquired) cases of acute hepatitis E virus have been recently reported in several developed countries. Aim: To evidence cases, if any, and characteristics of acute hepatitis E virus infections in North-East of Italy several years ago. Methods: In 2014, stored sera of 165 nonA–nonB acute hepatitis referred to the hospital of Padua during the period 1978–1991 were tested for hepatitis C virus antibodies by EIA III and for anti-hepatitis E virus IgM by Wantai HEV IgM ELISA. Anti-hepatitis E virus IgM positive sera were tested by Real Star HEV RT-PCR kit (Altona Diagnostics, Hamburg, Germany). Results: Ninety-six (58.1%) sera resulted anti-HCV positive, and thus classified as acute C hepatitis. None of these subjects was anti-HEV IgM positive. Out of the 69 anti-HCV negative cases, 4 (5.8%) resulted anti-HEV IgM positive (one case hepatitis E virus-RNA positive), with an increasing trend from 2.8% during the years 1978–1984 to 9.1% during the years 1985–1991. All cases occurred in Italian patients with no travel abroad history. Conclusions: There is evidence for the presence of autochthonous cases of acute hepatitis E virus infections in Italy since 80s. © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
1. Introduction Hepatitis E virus (HEV) is an enterically transmitted virus highly endemic throughout Central and Southern Asia, India, the Middle East, and North Africa [1], where it is mostly a water-born infection. In contrast, in developed countries, HEV was traditionally thought to occur infrequently and only in people who had become infected while travelling in an endemic area [2]. Over the last few years cases of sporadic HEV in subjects with no history of recent travel have been reported in the western world [3], leading to the acceptance that autochthonous (locally acquired) hepatitis E is a clinical problem in developed world. A recent long term prospective study from Italy has shown that during the period 1994–2009, 16.4% of acute HEV infections were classified as autochthonous cases, since all denied travel abroad [4].
⁎ Corresponding author at: Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299-00161 Rome, Italy. Tel.: +39 06 4990 3288. E-mail address: [email protected] (M. Rapicetta).
Using updated tests applied to stored sera we have reevaluated the aetiology of all acute nonA–nonB hepatitis cases consecutively referring during the period 1978–1991 to a single Institution in North-East of Italy. The aim was to evidence cases, if any, and characteristics of acute HEV infections. 2. Materials and methods A prospective follow-up study of acute viral hepatitis in adult patients was started at the Department of Infectious Diseases in Padua Hospital in June 1978 and ended in December 1991. The aim was to evaluate the aetiology and epidemiological pattern of the disease in the area [5]. The department was the unique institution in the town as referral centre for acute symptomatic hepatitis for an estimated population of 550,000 inhabitants. Patient referral pattern did not change over the years: no other referral institutions were activated in the area and no substantial demographic changes occurred. All patients were of Caucasian origin. The diagnosis of acute hepatitis was based on the clinical history (recent onset of signs and symptoms) and biochemical features (higher than fivefold increase of alanine aminotransferase). Viral hepatitis was
http://dx.doi.org/10.1016/j.ejim.2015.03.012 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
T. Stroffolini et al. / European Journal of Internal Medicine 26 (2015) 348–350
diagnosed after the exclusion of other potential causes of non-viral damage, such as alcohol abuse, assumption of potentially hepatotoxic drugs and biliary diseases, and autoimmune hepatitis. NonA–nonB hepatitis was defined by exclusion on the basis of negativity for anti-HAV IgM, anti-HBc IgM, anti-EBV IgM, and anti-CMV IgM as previously described [5]. In 2014, stored sera (− 20 °C) of subjects labelled as acute nonA– nonB hepatitis were tested for anti-HCV by ORTHO HCV 3.0 ELISA test system with enhanced SAVe (ORTHO Clinical Diagnostic Inc., Raritan, NJ, USA) and for anti-HEV IgM by Wantai HEV IgM ELISA (Beijing Wantai Biological, Beijing, China) [Fig. 1]. Anti-HEV IgM positive cases were tested for HEV-RNA detection. Briefly, HEV-RNA was extracted from 200 μl of serum using silica columns provided with the QIAamp MinElute Virus Spin kit (Qiagen, Hilden, Germany) according to the manufacturer's instructions. 100 μl of serum equivalent was amplified using the RealStar HEV RT-PCR kit, version 1.0, by Altona Diagnostics (Hamburg, Germany) on Roto-Gene Q 5/6 plex Platform (Qiagen). This kit includes primers and a probe targeting ORF3 region and is able to also detect different subtypes of HEV genotype 3. Its sensitivity, reported as 95% limit of detection, was assessed to be 50 IU/ml of HEV-RNA. In order to have an estimation of viral load in HEV positive samples, an external standard curve was applied and made of log dilution series of HEV-RNA WHO International Standard code 6329/10 (Paul Ehrlich Institute, Langen, Germany) from 5 × 104 to 5 × 101 IU/ml. The determinations were performed at the Department of Infectious, Parasitic and Immune Mediated Diseases and at the Centre for Immunobiological Research and Evaluation of the Istituto Superiore di Sanità, Rome, Italy. Information on demographic characteristics was obtained from patient's records and introduced in a computer database. Difference in proportion was evaluated by Fisher's exact test. A p value b0.05 was considered to be significant. The study protocol included informed consent from patients and was conducted according to the ethical guidelines of the 1975 declaration of Helsinki. 3. Results Overall, 165 subjects diagnosed as acute nonA–nonB during the period 1978–1991 have been evaluated in 2014 [Fig. 1]. Their socio-
349
demographic and clinical characteristics are reported in Table 1. 96 patients out of 165 (58.1%) resulted anti-HCV positive, and thus classified as acute C hepatitis. None of these subjects was anti-HEV IgM positive. 69 patients out of 165 (41.8%) were anti-HCV negative acute cases (nonA–C hepatitis), of these, 4 (5.8%) were anti-HEV IgM positive (2.4% referred to total population) and thus defined acute HEV hepatitis. While 65 (39.4% referred to total population) resulted anti-HEV IgM negative and thus defined acute nonA–E hepatitis [Fig. 2]. During the years 1978–1984 one HEV case (2.8%) occurred among the 36 A–C negative cases; while the corresponding figure during the years 1985–1991 was 3 acute HEV cases (9.1%) among 33 A–C negative cases (p = 0.3, not significant by Fisher's exact test). One out of the four anti-HEV IgM positive cases also resulted HEV-RNA positive (117 IU/ml). All four cases occurred in Italian subjects with no travel abroad, blood transfusion and intravenous drug use history. All cases recovered.
4. Discussion The present findings, restricted to a single referral center, evidence that autochthonous acute HEV was present in North-East of Italy since 80s, with an increasing trend, even if no statistically significant, over time. In fact, all 4 patients denied to have travelled abroad. Autochthonous hepatitis E in developed regions is frequently misdiagnosed as drug-induced liver injury. A retrospective analysis in a U.K. study showed that 21.0% of 28 patients who met the standard criteria for drug-induced liver injury did not have the condition, but instead had autochthonous hepatitis E [6]. Various lines of evidence may support the zoonotic transmission of HEV in non-endemic regions [7]. The first evidence of the close relationship among partial nucleotide sequences from two pigs and two human genotype 3 HEV strains was provided in the USA [8]. HEV has been found in domestic pigs, wild boar, deer, mongoose and bivalves [9–12]. The most likely route of transmission to humans is consuming raw or undercooked meat of infected wild animals such as meat of boars and deers and domestic animals such as pigs [13–15]. In infected animals the identified HEV was genotype 3 or 4 [3,16]. In Italy, HEV genotype 3 is widespread among farm pigs and wild boars. In recent Italian studies, HEV was detected in stools collected from 42% of randomly selected healthy pigs from six different swine farms and from bile samples of 25% of wild boars [17]. Phylogenetic analysis demonstrated that distinct subtypes of genotype 3 and subtype d of genotype 4 were circulating in swine population of North-East of Italy [18]. Generally, genotype 3 does not produce disease in swine [19]. This less virulent genotype may result in subclinical inapparent infections that only rarely cause clinical disease in immuno-competent human hosts. A sharp increase of the number of HEV genotype 3 infections was observed between the 1980 and 2005 by skyline plot analysis of databank isolates from Europe and other developed countries [20]. Accordingly, in the present study three out of four autochthonous (locally acquired) acute HEV cases were detected in the more recent group (1985–1991) Table 1 Characteristics of the no. 165 acute nonA–nonB hepatitis cases. Characteristic
Fig. 1. Diagnostic algorithm of the studied population. Anti-HAV IgM: hepatitis A virus IgM class antibody; anti-HBc IgM: hepatitis B virus core IgM class antibody; anti-EBV IgM: Epstein Barr virus IgM class antibody; anti-CMV IgM: cytomegalovirus IgM class antibody; anti-HCV: hepatitis C virus antibody; anti-HEV IgM: hepatitis E virus IgM class antibody; nonA-nonB hepatitis: hepatitis cases negative for hepatitis A and B; nonA–C hepatitis: hepatitis cases negative for hepatitis A, B and C; nonA–E hepatitis: hepatitis cases negative for A, B, C and E.
Mean age (years) Sex ratio (M/F) ALT (mean IU/ml) Bilirubin (mean g/ml) Source of exposure: Intravenous drug use Blood transfusion ALT: alanine transaminase. IU: international units. SD: standard deviation.
35.8 (SD: ±17.8) 1.3 1343.5 (SD: ±908.2) 27.2 (SD: ±54.4) 33.7% 15.3%
350
T. Stroffolini et al. / European Journal of Internal Medicine 26 (2015) 348–350
• These data are in accordance with those of other recent reports on the presence in several developed countries, of zoonotic HEV infections. • The importance of including HEV testing in diagnostic algorithms of acute hepatitis is enlightened.
Conflict of interests All the authors declare that they have no conflict of interest.
References
Fig. 2. Aetiology of no. 165 acute nonA–nonB hepatitis in Padua, 1978–1991, retested in 2014. NonA–nonB hepatitis: hepatitis cases negative for hepatitis A and B; anti-HCV: hepatitis C Virus antibody; anti-HEV IgM: hepatitis E virus IgM class antibody; nonA–C hepatitis: hepatitis cases negative for hepatitis A, B and C; nonA–E hepatitis: hepatitis cases negative for A, B, C and E.
of nonA–C hepatitis patients. The full viral characterization and genotyping was not possible, as sera have been stored for several years with possible occurrence of significant decrease of viral RNA titre. In fact, only one out of four anti-HEV IgM positive cases was also HEV RNA positive reflecting the decrease of viral RNA titre in the remaining other three cases. In conclusion, there is evidence for the presence of autochthonous cases of acute HEV in Italy since several years. In the diagnostic algorithm of acute nonA–C hepatitis it is advisable to perform HEV markers, even in people who denied travel abroad history. Learning points • A retrospective follow-up study (1978–1991) on acute nonA–nonB hepatitis cases, collected in a single referral centre in northern Italy, showed the presence of autochthonous acute hepatitis E infections. • An increasing trend of cases, despite no statistically significant, was observed during the considered period.
[1] Aggarwal R, Naik S. Epidemiology of hepatitis E: current status. J Gastroenterol Hepatol 2009;24:1484–93. [2] Schwartz E, Jenks NP, Van Damme P, Galun E. Hepatitis E virus infection in travelers. Clin Infect Dis 1999;29:1312–4. [3] Dalton HR, Bendall R, Ijaz S, Banks M. Hepatitis E: an emerging infection in developed countries. Lancet Infect Dis 2008;8:698–709. [4] Romano' L, Paladini S, Tagliacarne C, Canuti M, Bianchi S, Zanetti AR. Hepatitis E in Italy: a long-term prospective study. J Hepatol 2011;54:34–40. [5] Bortolotti F, Cadrobbi P, Carretta M, Meneghetti F, Pornaro E, Realdi G. Epidemiological aspects on acute viral hepatitis in northern Italy. Scand J Infect Dis 1982;14:161–4. [6] Dalton HR, Fellows HJ, Stableforth W, Joseph M, Thurairajah PH, Warshow U, et al. The role of hepatitis E virus testing in drug-induced liver injury. Aliment Pharmacol Ther 2007;26:1429–35. [7] Pavio N, Meng XJ, Doceul V. Zoonotic origin of hepatitis E. Virology 2015;10:34–41. [8] Meng XJ, Purcell RH, Halbur PG, Lehman JR, Webb DM, Tsareva TS, et al. A novel virus in swine is closely related to the human hepatitis E virus. Proc Natl Acad Sci U S A 1997;94:9860–5. [9] Aniţă A, Gorgan L, Aniţă D, Oşlobanu L, Pavio N, Savuţa G. Evidence of hepatitis E infection in swine and humans in the East Region of Romania. 2014;29:232–7. [10] Takahashi K, Kitajima N, Abe N, Mishiro S. Complete or near-complete nucleotide sequences of hepatitis E virus genome recovered from a wild boar, a deer, and four patients who ate the deer. Virology 2004;330:501–5. [11] Kukielka D, Rodriguez-Prieto V, Vicente J, Sánchez-Vizcaíno JM. Constant hepatitis E virus (HEV) circulation in wild boar and red deer in Spain: an increasing concern source of HEV zoonotic transmission. Transbound Emerg Dis 2015. http://dx.doi. org/10.1111/tbed.12311. [12] Gao S, Li D, Zha E, Zhou T, Wang S, Yue X. Surveillance of hepatitis E virus contamination in China. Int J Environ Res Public Health 2015;12:2026–36. [13] Berto A, Grierson S, Hakze-van der Honing R, Martelli F, Johne R, Reetz J, et al. Hepatitis E virus in pork liver sausage, France. Emerg Infect Dis 2013;19:264–6. [14] Colson P, Borentain P, Queyriaux B, Kaba M, Moal V, Gallian P, et al. Pig liver sausage as a source of hepatitis E virus transmission to humans. J Infect Dis 2010;202:825–34. [15] Di Bartolo I, Angeloni G, Ponterio E, Ostanello F, Ruggeri FM. Detection of hepatitis E virus in pork liver sausages. Int J Food Microbiol 2015;193:29–33. [16] Meng XJ. From barnyard to food table: the omnipresence of hepatitis E virus and risk for zoonotic infection and food safety. Virus Res 2011;161:23–30. [17] Di Bartolo I, Martelli F, Inglese N, Pourshaban M, Caprioli A, Ostanello F, et al. Widespread diffusion of genotype 3 hepatitis E virus among farming swine in Northern Italy. Vet Microbiol 2008;132:47–55. [18] Monne I, Ceglie L, Di Martino G, Natale A, Zamprogna S, Morreale A, et al. Hepatitis E virus genotype 4 in a pig farm, Italy, 2013. Epidemiol Infect 2014;15:1–5. [19] Purcell RH, Emerson SU. Hepatitis E: an emerging awareness of an old disease. J Hepatol 2008;48:494–503. [20] Zehender G, Ebranati E, Lai A, Luzzago C, Paladini S, Tagliacarne C, et al. Phylogeography and phylodynamics of European genotype 3 hepatitis E virus. Infect Genet Evol 2014;25:138–43.
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Original Article
Evidence for the presence of autochthonous (locally acquired) cases of acute hepatitis E virus infections in Italy since the 80s Tommaso Stroffolini a, Maria Rapicetta b,⁎, Paola Chionne b, Rozenn Esvan a, Elisabetta Madonna b, Flavia Lombardo c, Fabrizio Toccaceli a, Giulio Pisani d, Annarita Ciccaglione b, Flavia Bortolotti e a
Department of Infectious and Tropical Diseases, Policlinico Umberto I, Rome, Italy Viral Hepatitis Unit, Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy National Center for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy d Center for Immunobiological Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy e Department of Experimental and Clinical Medicine, University of Padua, Italy b c
a r t i c l e
i n f o
Article history: Received 21 January 2015 Received in revised form 18 March 2015 Accepted 29 March 2015 Available online 14 April 2015 Keywords: Hepatitis E HEV HCV Acute infection Epidemiology Italy
a b s t r a c t Background: Autochthonous (locally acquired) cases of acute hepatitis E virus have been recently reported in several developed countries. Aim: To evidence cases, if any, and characteristics of acute hepatitis E virus infections in North-East of Italy several years ago. Methods: In 2014, stored sera of 165 nonA–nonB acute hepatitis referred to the hospital of Padua during the period 1978–1991 were tested for hepatitis C virus antibodies by EIA III and for anti-hepatitis E virus IgM by Wantai HEV IgM ELISA. Anti-hepatitis E virus IgM positive sera were tested by Real Star HEV RT-PCR kit (Altona Diagnostics, Hamburg, Germany). Results: Ninety-six (58.1%) sera resulted anti-HCV positive, and thus classified as acute C hepatitis. None of these subjects was anti-HEV IgM positive. Out of the 69 anti-HCV negative cases, 4 (5.8%) resulted anti-HEV IgM positive (one case hepatitis E virus-RNA positive), with an increasing trend from 2.8% during the years 1978–1984 to 9.1% during the years 1985–1991. All cases occurred in Italian patients with no travel abroad history. Conclusions: There is evidence for the presence of autochthonous cases of acute hepatitis E virus infections in Italy since 80s. © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
1. Introduction Hepatitis E virus (HEV) is an enterically transmitted virus highly endemic throughout Central and Southern Asia, India, the Middle East, and North Africa [1], where it is mostly a water-born infection. In contrast, in developed countries, HEV was traditionally thought to occur infrequently and only in people who had become infected while travelling in an endemic area [2]. Over the last few years cases of sporadic HEV in subjects with no history of recent travel have been reported in the western world [3], leading to the acceptance that autochthonous (locally acquired) hepatitis E is a clinical problem in developed world. A recent long term prospective study from Italy has shown that during the period 1994–2009, 16.4% of acute HEV infections were classified as autochthonous cases, since all denied travel abroad [4].
⁎ Corresponding author at: Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299-00161 Rome, Italy. Tel.: +39 06 4990 3288. E-mail address: [email protected] (M. Rapicetta).
Using updated tests applied to stored sera we have reevaluated the aetiology of all acute nonA–nonB hepatitis cases consecutively referring during the period 1978–1991 to a single Institution in North-East of Italy. The aim was to evidence cases, if any, and characteristics of acute HEV infections. 2. Materials and methods A prospective follow-up study of acute viral hepatitis in adult patients was started at the Department of Infectious Diseases in Padua Hospital in June 1978 and ended in December 1991. The aim was to evaluate the aetiology and epidemiological pattern of the disease in the area [5]. The department was the unique institution in the town as referral centre for acute symptomatic hepatitis for an estimated population of 550,000 inhabitants. Patient referral pattern did not change over the years: no other referral institutions were activated in the area and no substantial demographic changes occurred. All patients were of Caucasian origin. The diagnosis of acute hepatitis was based on the clinical history (recent onset of signs and symptoms) and biochemical features (higher than fivefold increase of alanine aminotransferase). Viral hepatitis was
http://dx.doi.org/10.1016/j.ejim.2015.03.012 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
T. Stroffolini et al. / European Journal of Internal Medicine 26 (2015) 348–350
diagnosed after the exclusion of other potential causes of non-viral damage, such as alcohol abuse, assumption of potentially hepatotoxic drugs and biliary diseases, and autoimmune hepatitis. NonA–nonB hepatitis was defined by exclusion on the basis of negativity for anti-HAV IgM, anti-HBc IgM, anti-EBV IgM, and anti-CMV IgM as previously described [5]. In 2014, stored sera (− 20 °C) of subjects labelled as acute nonA– nonB hepatitis were tested for anti-HCV by ORTHO HCV 3.0 ELISA test system with enhanced SAVe (ORTHO Clinical Diagnostic Inc., Raritan, NJ, USA) and for anti-HEV IgM by Wantai HEV IgM ELISA (Beijing Wantai Biological, Beijing, China) [Fig. 1]. Anti-HEV IgM positive cases were tested for HEV-RNA detection. Briefly, HEV-RNA was extracted from 200 μl of serum using silica columns provided with the QIAamp MinElute Virus Spin kit (Qiagen, Hilden, Germany) according to the manufacturer's instructions. 100 μl of serum equivalent was amplified using the RealStar HEV RT-PCR kit, version 1.0, by Altona Diagnostics (Hamburg, Germany) on Roto-Gene Q 5/6 plex Platform (Qiagen). This kit includes primers and a probe targeting ORF3 region and is able to also detect different subtypes of HEV genotype 3. Its sensitivity, reported as 95% limit of detection, was assessed to be 50 IU/ml of HEV-RNA. In order to have an estimation of viral load in HEV positive samples, an external standard curve was applied and made of log dilution series of HEV-RNA WHO International Standard code 6329/10 (Paul Ehrlich Institute, Langen, Germany) from 5 × 104 to 5 × 101 IU/ml. The determinations were performed at the Department of Infectious, Parasitic and Immune Mediated Diseases and at the Centre for Immunobiological Research and Evaluation of the Istituto Superiore di Sanità, Rome, Italy. Information on demographic characteristics was obtained from patient's records and introduced in a computer database. Difference in proportion was evaluated by Fisher's exact test. A p value b0.05 was considered to be significant. The study protocol included informed consent from patients and was conducted according to the ethical guidelines of the 1975 declaration of Helsinki. 3. Results Overall, 165 subjects diagnosed as acute nonA–nonB during the period 1978–1991 have been evaluated in 2014 [Fig. 1]. Their socio-
349
demographic and clinical characteristics are reported in Table 1. 96 patients out of 165 (58.1%) resulted anti-HCV positive, and thus classified as acute C hepatitis. None of these subjects was anti-HEV IgM positive. 69 patients out of 165 (41.8%) were anti-HCV negative acute cases (nonA–C hepatitis), of these, 4 (5.8%) were anti-HEV IgM positive (2.4% referred to total population) and thus defined acute HEV hepatitis. While 65 (39.4% referred to total population) resulted anti-HEV IgM negative and thus defined acute nonA–E hepatitis [Fig. 2]. During the years 1978–1984 one HEV case (2.8%) occurred among the 36 A–C negative cases; while the corresponding figure during the years 1985–1991 was 3 acute HEV cases (9.1%) among 33 A–C negative cases (p = 0.3, not significant by Fisher's exact test). One out of the four anti-HEV IgM positive cases also resulted HEV-RNA positive (117 IU/ml). All four cases occurred in Italian subjects with no travel abroad, blood transfusion and intravenous drug use history. All cases recovered.
4. Discussion The present findings, restricted to a single referral center, evidence that autochthonous acute HEV was present in North-East of Italy since 80s, with an increasing trend, even if no statistically significant, over time. In fact, all 4 patients denied to have travelled abroad. Autochthonous hepatitis E in developed regions is frequently misdiagnosed as drug-induced liver injury. A retrospective analysis in a U.K. study showed that 21.0% of 28 patients who met the standard criteria for drug-induced liver injury did not have the condition, but instead had autochthonous hepatitis E [6]. Various lines of evidence may support the zoonotic transmission of HEV in non-endemic regions [7]. The first evidence of the close relationship among partial nucleotide sequences from two pigs and two human genotype 3 HEV strains was provided in the USA [8]. HEV has been found in domestic pigs, wild boar, deer, mongoose and bivalves [9–12]. The most likely route of transmission to humans is consuming raw or undercooked meat of infected wild animals such as meat of boars and deers and domestic animals such as pigs [13–15]. In infected animals the identified HEV was genotype 3 or 4 [3,16]. In Italy, HEV genotype 3 is widespread among farm pigs and wild boars. In recent Italian studies, HEV was detected in stools collected from 42% of randomly selected healthy pigs from six different swine farms and from bile samples of 25% of wild boars [17]. Phylogenetic analysis demonstrated that distinct subtypes of genotype 3 and subtype d of genotype 4 were circulating in swine population of North-East of Italy [18]. Generally, genotype 3 does not produce disease in swine [19]. This less virulent genotype may result in subclinical inapparent infections that only rarely cause clinical disease in immuno-competent human hosts. A sharp increase of the number of HEV genotype 3 infections was observed between the 1980 and 2005 by skyline plot analysis of databank isolates from Europe and other developed countries [20]. Accordingly, in the present study three out of four autochthonous (locally acquired) acute HEV cases were detected in the more recent group (1985–1991) Table 1 Characteristics of the no. 165 acute nonA–nonB hepatitis cases. Characteristic
Fig. 1. Diagnostic algorithm of the studied population. Anti-HAV IgM: hepatitis A virus IgM class antibody; anti-HBc IgM: hepatitis B virus core IgM class antibody; anti-EBV IgM: Epstein Barr virus IgM class antibody; anti-CMV IgM: cytomegalovirus IgM class antibody; anti-HCV: hepatitis C virus antibody; anti-HEV IgM: hepatitis E virus IgM class antibody; nonA-nonB hepatitis: hepatitis cases negative for hepatitis A and B; nonA–C hepatitis: hepatitis cases negative for hepatitis A, B and C; nonA–E hepatitis: hepatitis cases negative for A, B, C and E.
Mean age (years) Sex ratio (M/F) ALT (mean IU/ml) Bilirubin (mean g/ml) Source of exposure: Intravenous drug use Blood transfusion ALT: alanine transaminase. IU: international units. SD: standard deviation.
35.8 (SD: ±17.8) 1.3 1343.5 (SD: ±908.2) 27.2 (SD: ±54.4) 33.7% 15.3%
350
T. Stroffolini et al. / European Journal of Internal Medicine 26 (2015) 348–350
• These data are in accordance with those of other recent reports on the presence in several developed countries, of zoonotic HEV infections. • The importance of including HEV testing in diagnostic algorithms of acute hepatitis is enlightened.
Conflict of interests All the authors declare that they have no conflict of interest.
References
Fig. 2. Aetiology of no. 165 acute nonA–nonB hepatitis in Padua, 1978–1991, retested in 2014. NonA–nonB hepatitis: hepatitis cases negative for hepatitis A and B; anti-HCV: hepatitis C Virus antibody; anti-HEV IgM: hepatitis E virus IgM class antibody; nonA–C hepatitis: hepatitis cases negative for hepatitis A, B and C; nonA–E hepatitis: hepatitis cases negative for A, B, C and E.
of nonA–C hepatitis patients. The full viral characterization and genotyping was not possible, as sera have been stored for several years with possible occurrence of significant decrease of viral RNA titre. In fact, only one out of four anti-HEV IgM positive cases was also HEV RNA positive reflecting the decrease of viral RNA titre in the remaining other three cases. In conclusion, there is evidence for the presence of autochthonous cases of acute HEV in Italy since several years. In the diagnostic algorithm of acute nonA–C hepatitis it is advisable to perform HEV markers, even in people who denied travel abroad history. Learning points • A retrospective follow-up study (1978–1991) on acute nonA–nonB hepatitis cases, collected in a single referral centre in northern Italy, showed the presence of autochthonous acute hepatitis E infections. • An increasing trend of cases, despite no statistically significant, was observed during the considered period.
[1] Aggarwal R, Naik S. Epidemiology of hepatitis E: current status. J Gastroenterol Hepatol 2009;24:1484–93. [2] Schwartz E, Jenks NP, Van Damme P, Galun E. Hepatitis E virus infection in travelers. Clin Infect Dis 1999;29:1312–4. [3] Dalton HR, Bendall R, Ijaz S, Banks M. Hepatitis E: an emerging infection in developed countries. Lancet Infect Dis 2008;8:698–709. [4] Romano' L, Paladini S, Tagliacarne C, Canuti M, Bianchi S, Zanetti AR. Hepatitis E in Italy: a long-term prospective study. J Hepatol 2011;54:34–40. [5] Bortolotti F, Cadrobbi P, Carretta M, Meneghetti F, Pornaro E, Realdi G. Epidemiological aspects on acute viral hepatitis in northern Italy. Scand J Infect Dis 1982;14:161–4. [6] Dalton HR, Fellows HJ, Stableforth W, Joseph M, Thurairajah PH, Warshow U, et al. The role of hepatitis E virus testing in drug-induced liver injury. Aliment Pharmacol Ther 2007;26:1429–35. [7] Pavio N, Meng XJ, Doceul V. Zoonotic origin of hepatitis E. Virology 2015;10:34–41. [8] Meng XJ, Purcell RH, Halbur PG, Lehman JR, Webb DM, Tsareva TS, et al. A novel virus in swine is closely related to the human hepatitis E virus. Proc Natl Acad Sci U S A 1997;94:9860–5. [9] Aniţă A, Gorgan L, Aniţă D, Oşlobanu L, Pavio N, Savuţa G. Evidence of hepatitis E infection in swine and humans in the East Region of Romania. 2014;29:232–7. [10] Takahashi K, Kitajima N, Abe N, Mishiro S. Complete or near-complete nucleotide sequences of hepatitis E virus genome recovered from a wild boar, a deer, and four patients who ate the deer. Virology 2004;330:501–5. [11] Kukielka D, Rodriguez-Prieto V, Vicente J, Sánchez-Vizcaíno JM. Constant hepatitis E virus (HEV) circulation in wild boar and red deer in Spain: an increasing concern source of HEV zoonotic transmission. Transbound Emerg Dis 2015. http://dx.doi. org/10.1111/tbed.12311. [12] Gao S, Li D, Zha E, Zhou T, Wang S, Yue X. Surveillance of hepatitis E virus contamination in China. Int J Environ Res Public Health 2015;12:2026–36. [13] Berto A, Grierson S, Hakze-van der Honing R, Martelli F, Johne R, Reetz J, et al. Hepatitis E virus in pork liver sausage, France. Emerg Infect Dis 2013;19:264–6. [14] Colson P, Borentain P, Queyriaux B, Kaba M, Moal V, Gallian P, et al. Pig liver sausage as a source of hepatitis E virus transmission to humans. J Infect Dis 2010;202:825–34. [15] Di Bartolo I, Angeloni G, Ponterio E, Ostanello F, Ruggeri FM. Detection of hepatitis E virus in pork liver sausages. Int J Food Microbiol 2015;193:29–33. [16] Meng XJ. From barnyard to food table: the omnipresence of hepatitis E virus and risk for zoonotic infection and food safety. Virus Res 2011;161:23–30. [17] Di Bartolo I, Martelli F, Inglese N, Pourshaban M, Caprioli A, Ostanello F, et al. Widespread diffusion of genotype 3 hepatitis E virus among farming swine in Northern Italy. Vet Microbiol 2008;132:47–55. [18] Monne I, Ceglie L, Di Martino G, Natale A, Zamprogna S, Morreale A, et al. Hepatitis E virus genotype 4 in a pig farm, Italy, 2013. Epidemiol Infect 2014;15:1–5. [19] Purcell RH, Emerson SU. Hepatitis E: an emerging awareness of an old disease. J Hepatol 2008;48:494–503. [20] Zehender G, Ebranati E, Lai A, Luzzago C, Paladini S, Tagliacarne C, et al. Phylogeography and phylodynamics of European genotype 3 hepatitis E virus. Infect Genet Evol 2014;25:138–43.
