Successful recovery from acute-on-chronic liver failure due to acute hepatitis E virus superinfection in chronic hepatitis B: A case report

Introduction: Acute hepatitis E virus (HEV) infection is a self-limiting disease, but HEV superinfection in patients with chronic hepatitis B virus (HBV) infection may lead to acute-on-chronic liver failure (ACLF) and significantly increase short-term mortality. Diagnosis and comprehensive management of these patients remain in a dilemma. Case presentation: A 32-year-old man with chronic HBV infection for 8 years received entecavir due to abnormal liver function for 4 months. He was admitted for symptomatic hepatitis flare for nearly 2 weeks. Initial investigations did not reveal a cause other than HBV, but repeated tests showed a progressive increase in his antiHEV IgM. His condition worsened rapidly. Mid-stage ACLF and spontaneous peritonitis were diagnosed. Entecavir and hepatoprotective drugs were continued. Ribavirin, ceftriaxone, and repeated artificial liver support system (ALSS) therapy were administered. His condition gradually improved and his liver function eventually returned to normal. Conclusions: Repeated HEV screening is important for patients with chronic liver disease and symptomatic hepatitis flare. Negative anti-HEV IgM for the first time can easily lead clinicians to mistakenly rule out HEV infection. A progressive increase in anti-HEV IgM is one of the diagnostic criteria for HEV infection, which is not rare but deserves attention. Additionally, comprehensive management including ribavirin and ALSS would be effective therapies for patients who superinfect with HEV and develop ACLF.