A 38-year-old man from rural India presents with jaundice, dark urine, and right upper quadrant pain. Serum ALT is 2800 U/L, bilirubin 8.2 mg/dL, and INR is 1.8. Serological testing shows anti-HEV IgM positive and anti-HEV IgG negative. Regarding hepatitis E virus (HEV) infection, all of the following are true EXCEPT:

Question

Accepted Answer

B. Chronic HEV infection is common in immunocompetent individuals and requires long-term antiviral therapy. ## Hepatitis E Virus (HEV) — Clinical & Epidemiological Features

**Key Point:** Chronic HEV infection is NOT common in immunocompetent individuals; it is rare and self-limited. Chronic HEV occurs almost exclusively in immunocompromised hosts (transplant recipients, HIV+ patients with CD4 <200).

### HEV Virology & Transmission

| Feature | Details |
|---------|----------|
| **Genome** | Non-enveloped, single-stranded RNA (+ssRNA) |
| **Family** | Hepeviridae |
| **Transmission** | Primarily fecal-oral (waterborne in endemic areas) |
| **Incubation** | 15–60 days (average 40 days) |
| **Acute infection outcome** | Self-limited in >95% of immunocompetent hosts |
| **Chronic infection** | Rare in immunocompetent; common in immunocompromised |

**High-Yield:** HEV is the ONLY hepatitis virus that causes fulminant hepatic failure preferentially in pregnant women (15–25% mortality in 3rd trimester vs. 0.5–4% in non-pregnant).

### HEV Genotypes & Epidemiology

| Genotype | Geography | Transmission | Outcome |
|----------|-----------|--------------|----------|
| **1 & 2** | Developing countries (Asia, Africa, Latin America) | Waterborne epidemics | Acute, self-limited |
| **3 & 4** | Developed countries (Europe, North America, Japan) | Zoonotic (pigs, deer) | Acute, rarely chronic in immunocompromised |

**Mnemonic:** **HEV-FETAL** — HEV causes Fulminant hepatitis in prEgnancy, especially in the Third trimester, with high mALtality.

### Why Each Statement Is Correct (Except One)

1. **Non-enveloped ssRNA, fecal-oral transmission** ✓ (Correct)
2. **Chronic HEV common in immunocompetent** ✗ (INCORRECT — this is the answer)
3. **Pregnant women at high risk of fulminant failure** ✓ (Correct — 15–25% mortality in 3rd trimester)
4. **Genotypes 1 & 2 cause waterborne epidemics** ✓ (Correct)

**Clinical Pearl:** This patient's presentation (acute hepatitis in rural India, anti-HEV IgM+) is consistent with acute HEV. The elevated INR (1.8) suggests impending liver synthetic dysfunction but does not indicate chronic disease; acute HEV resolves in 4–6 weeks in immunocompetent individuals.

**Warning:** Do not confuse HEV with HCV. HCV causes chronic infection in 70–85% of cases; HEV does NOT. Chronic HEV is a diagnosis reserved for immunocompromised patients with persistent HEV RNA beyond 6 months.

Answer

A. Pregnant women infected with HEV have a significantly higher risk of fulminant hepatic failure compared to non-pregnant women

Answer

C. HEV is a non-enveloped, single-stranded RNA virus transmitted primarily via the fecal-oral route

Answer

D. HEV genotypes 1 and 2 are associated with large waterborne epidemics in developing countries

Explanation

Hepatitis E Virus (HEV) — Clinical & Epidemiological Features

HEV Virology & Transmission

HEV Genotypes & Epidemiology

Why Each Statement Is Correct (Except One)

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Feature	Details
Genome	Non-enveloped, single-stranded RNA (+ssRNA)
Family	Hepeviridae
Transmission	Primarily fecal-oral (waterborne in endemic areas)
Incubation	15–60 days (average 40 days)
Acute infection outcome	Self-limited in >95% of immunocompetent hosts
Chronic infection	Rare in immunocompetent; common in immunocompromised

Genotype	Geography	Transmission	Outcome
1 & 2	Developing countries (Asia, Africa, Latin America)	Waterborne epidemics	Acute, self-limited
3 & 4	Developed countries (Europe, North America, Japan)	Zoonotic (pigs, deer)	Acute, rarely chronic in immunocompromised