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Medicine (Baltimore). 2015 Apr;94(14):e675. doi: 10.1097/MD.0000000000000675.

Outcome of hepatitis E virus infection in patients with inflammatory arthritides treated with immunosuppressants: a French retrospective multicenter study.

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From the Service de Rhumatologie (HB, J-EG, EC, CS, JS), Centre de Référence des Maladies Auto-Immunes Systémiques Rares, C.H.U. de Hautepierre, Strasbourg; Service de Rhumatologie (CL, AC); Service d'Hépato-gastro-entérologie (SF, J-MP); Laboratoire de Virologie (FA, JI), C.H.U. Purpan, Toulouse; Service de Rhumatologie (PC), C.H.U. Henri Mondor, Créteil; Service de Rhumatologie (CH, AM), C.H.U Cochin, Paris; Service d'Immunologie Clinique et Thérapeutique Ostéo-Articulaire (SF, Y-MP), C.H.U. Lapeyronie, Montpellier; Service de Médecine Interne (GL), C.H.R.U. de Lille; Service de Rhumatologie (LM), Institut Calot, Berck-s-Mer; Service de Rhumatologie (AM), C.H. de Saint Brieuc; Service de Médecine Interne et de Rhumatologie (LM), C.H. Pasteur, Colmar; Service de Rhumatologie (BP-P), C.H.U. Bellevue, Saint Etienne; Laboratoire de Virologie (AM-RA), Hôpital Paul Brousse, Villejuif; Service de Rhumatologie (CR), Hôpital de l'Archet 1, Nice; Service de Rhumatologie (MS), C.H.U. de Clermont-Ferrand; Service de Rhumatologie (CV), C.H.U. Pellegrin, Bordeaux; and Service de Rhumatologie (DW), C.H.U. Minjoz, Besançon, France.


The clinical presentation and outcome of hepatitis E virus (HEV) infection in inflammatory rheumatic diseases are unknown. We aimed to investigate the severity of acute HEV infection and the risk of chronic viral replication in patients with inflammatory arthritides treated with immunosuppressive drugs. All rheumatology and internal medicine practitioners belonging to the Club Rhumatismes et Inflammation in France were sent newsletters asking for reports of HEV infection and inflammatory arthritides. Baseline characteristics of patients and the course of HEV infection were retrospectively assessed by use of a standardized questionnaire. From January 2010 to August 2013, we obtained reports of 23 cases of HEV infection in patients with rheumatoid arthritis (n = 11), axial spondyloarthritis (n = 5), psoriatic arthritis (n = 4), other types of arthritides (n = 3). Patients received methotrexate (n = 16), antitumor necrosis factor α agents (n = 10), rituximab (n = 4), abatacept (n = 2), tocilizumab (n = 2), and corticosteroids (n = 10, median dose 6 mg/d, range 2-20). All had acute hepatitis: median aspartate and alanine aminotransferase levels were 679 and 1300 U/L, respectively. Eleven patients were asymptomatic, 4 had jaundice. The HEV infection diagnosis relied on positive PCR results for HEV RNA (n = 14 patients) or anti-HEV IgM positivity (n = 9). Median follow-up was 29 months (range 3-55). Treatment included discontinuation of immunosuppressants for 20 patients and ribavirin treatment for 5. Liver enzyme levels normalized and immunosuppressant therapy could be reinitiated in all patients. No chronic infection was observed. Acute HEV infection should be considered in patients with inflammatory rheumatism and elevated liver enzyme values. The outcome of HEV infection seems favorable, with no evolution to chronic hepatitis or fulminant liver failure.

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