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:

Explanation

## 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.