Recently, a ski guide in his mid 20's got in touch with us to describe what happened to him following a winter season in the French Alps. Two weeks after returning to the UK he quickly developed jaundice, fatigue and limb weakness. He was urgently referred to a liver specialist and admitted for investigations. Over the course of a few days the weakness worsened and he was transferred to the High Dependency Unit (HDU). Here, he was diagnosed with Guillian Barre Syndrome (GBS). Fortunately, his respiratory function was unaffected and mechanical ventilation was not required. He was discharged from HDU 7 days later. After a further 3 weeks on the wards he went home, however it would be 2 years before he could return to work.
During his admission, tests for viral hepatitis revealed a positive PCR and IgM serology for Hepatitis E. Whilst this form of hepatitis would not normally warrant treatment, the presence of GBS led clinicians to prescribe ribavarin*. This was continued until the patient's clinical picture started to improve.
Hepatitis E has an incubation period of up to 8 weeks. An initial spike in alanine aminotransferase (ALT) is accompanied by increases in IgM and IgG antibody concentration. IgG antibody remains persistently elevated following infection.
Hepatitis E is rapidly becoming the commonest form of viral hepatitis in Europe. In south west France 52% of the adult population has evidence of previous infection (IgG antibody). In Scotland a 15 fold increase in Hepatitis E diagnosis was found between 2011 and 2016. Historically, the infection was picked up as a result of travel to developing countries. Here, it is estimated that more than 20 million infections (genotype 1 and 2) occur each year. In these countries, the mode of infection is primarily through the faecal-oral route and there is no known vector. However, the majority of infections in Europe now results from contact with domestic pigs (genotype 3 and 4). Hepatitis E has been found to be present in 1% of Scottish shellfish. This is thought to be due to abattoir effluent and pasture run off contaminating waterways in which the shellfish are farmed.
In Europe, the majority of Hepatitis E infection is contracted from domestic pigs. This may be due to consumption of undercooked pork, infected shellfish or foodstuffs that have come into contact with pig waste products. Therefore it is vital that pork and shellfish are properly cooked and that all foodstuffs are washed with clean water prior to consumption.
Although rare, complications from Hepatitis E do occur. This is only likely to increase with growing rates of infection. Whilst treatment of Hepatitis E is largely supportive, those who are immunosuppressed, suffering from chronic liver impairment or have life threatening complications may warrant antiviral treatment.
*An antiviral medication that is normally reserved for immunocompromised patients or those with pre-existing liver impairment. The best way to treat recognised complications of Hepatitis E, including GBS, has not been established.
We would like to thank the ski guide for getting in touch and sharing his story.
The British Mountain Medicine Society (BMMS) are organising a Science Day in the Peak District on the 13th November 2019. Why not come along? Details can be found here.