Chronic Hepatitis E and Organ Transplants

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Abstract
Kamar and colleagues (Feb. 21 issue)1 report eight cases of chronic hepatitis E virus (HEV) infection in immunosuppressed organ-transplant recipients, a constellation that was hitherto not observed. One wonders whether the persistence of HEV infection is a more general consequence of immunosuppression, which has implications for all so-called nonpersistent pathogens. Previously, we observed prolonged and possibly chronic shedding of human metapneumovirus in two patients with cancer who were immunosuppressed because they were receiving chemotherapy.2 Furthermore, it was recently reported that immunosuppression induced by lactate dehydrogenase–elevating virus led to increases in the severity and duration of the acute phase of friend virus infection in mice, most likely because of diminished CD8− responses.3 Such observations may provide support for earlier assumptions that if the CD4+ defense is insufficient because of immunosuppression, the CD8− response is unlikely to eliminate infection.4 The study by Kamar et al. revealed significantly reduced CD4− counts in patients with chronic HEV infection. Under these specific circumstances, so-called nonpersistent viruses may cause chronic colonization and recurrent infection. Hence, reducing drug-induced immunosuppression during acute HEV infection might be a strategy to prevent the progression to chronic hepatitis.