Background/Purpose: In inflammatory rheumatic diseases, the prevalence, clinical presentation and outcome of hepatitis E, an ubiquitous viral infection, remain unknown. We therefore addressed these issues in a large retrospective study. The main objective of this study was to investigate the severity of acute hepatitis E and the risk of chronic viral replication  in patients suffering from inflammatory rheumatisms and treated with immunosuppressive drugs.

Methods: All French rheumatology and internal medicine practitioners registered on the Club Rhumatisme et Inflammation (nearly 2,000 physicians),were repeatedly sent newsletters asking to report observations of acute hepatitis E virus (HEV) infection in patients with inflammatory arthritides. They were subsequently sent a standardized and detailed questionnaire on baseline characteristics of the patients and the course of HEV infection.

Results: Nineteen observations of hepatitis E were collected. They occurred in patients with rheumatoid arthritis (n = 9), axial spondyloarthritis (n = 4), psoriatic arthritis (n = 3), juvenile idiopathic arthritis (n =1), Jaccoud arthropathy (n = 1) and undifferentiated arthritis (n = 1),  treated with methotrexate (n = 13), anti-TNFα therapy (n = 6), rituximab (n = 4), abatacept (n = 3) or tocilizumab (n = 1). Eight patients were treated with corticosteroids with a median dose of 4.5 mg/d. Most of the patients had few symptoms, except asthenia. A woman, suffering from psoriatic arthritis treated with cyclosporine developed a bilateral Parsonage Turner syndrome, which was considered as an extrahepatic HEV-related manifestation. All of the patients had acute elevation of aspartate and alanine aminotransferase levels, and 7 patients also had moderate cholestasis. Two patients had an acute hepatic failure with decreased prothrombin time. The hepatitis E diagnosis either relied on positive PCR detection for HEV RNA (n = 13 patients), or on positive IgM result without PCR assessment (n = 2) or with negative PCR for HEV (n = 4). No other aetiology of the hepatitis could be found, except in 1 patient who had a HEV and HAV coinfection. Mean current follow-up is 13.4 months (standard deviation: 8.8 months). Treatment of HEV infection included the discontinuation of immunosuppressants in 18 out of 19 patients (adalimumab was maintained in 1 patient) and ribavirine in 5 patients. Liver enzymes normalized within 1 month in 7 patients, 3 months in 6 patients, and 4 months in 2 patients. Ten previously positive PCR tests were repeated and all became negative within 3 months after HEV infection.Among the 15 patients with a follow-up of at least 3 months, all are considered to be cured by their clinicians and an immunosuppressant (the same as before HEV infection in 14 patients, etanercept in 1 patient) could be reinitiated in all of them with no viral reactivation.

Conclusion: The diagnosis of acute hepatitis E should be considered in patients with inflammatory arthritides treated with immunosuppressants and elevated liver enzymes. The outcome of HEV infection is usually favourable, after transient discontinuation of immunosuppressants associated or not with ribavirin, with no reported evolution towards chronicity.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/favorable-outcome-of-hepatitis-e-virus-infection-in-patients-with-inflammatory-arthritides-treated-with-immunosupressants/