Year : 2017 | Volume : 5 | Issue : 2 | Page : 82 - 83  

Case Reports
A Case Report of the Dual Infection with HAV and HEV in A Pediatric Patient at Lotus Hospital, Hyderabad

Kulkarni Grishma V

Consultant Microbiologist, Max Cure Hospital, Hyderabad, Telangana, India



Acute viral hepatitis is a major public health problem and is important cause of morbidity and mortality.HAV and HEV are the enterically transmitted viruses, resulting in acute viral hepatitis in the developing countries .The aim of the presentation of this case report is to emphasize on the screening of HAV and HEV in the patients with acute viral hepatitis as seroprevalence of the coexistence of this infection is higher in our country.

Keywords: Acute viral hepatitis, HAV, HEV


Communicable diseases are still major health problem in our country. 1 HAV (Hepatitis A virus) and HEV (Hepatitis E virus) are enterically transmitted viruses resulting in sporadic and epidemic forms of acute hepatitis in the developing countries including India. 2 Though the prevalence of HAV is much higher than HEV, the co-infection rate of 11.5% mandates the screening of HEV which will be of immense importance in pregnant women and in improving the levels of the personal hygiene among the population of our country. 2

This case report of acute hepatitis because of the co-infection with HAV and HEV is presented as this was a rare finding in pediatric patient in the last 6 months in our hospital


A 4 year old boy was admitted to Lotus hospital, Hyderabad on 03/12/14, with the complaints of fever, vomiting, abdominal pain since 2 days and yellowish discolouration of urine since one day. The child’s growth and developmental milestones were normal. He was immunised with BCG, OPV and DPT as per Indian National immunization schedule. There was no specific past history of any major illness.

On examination, temperature was 99.7 degree F, HR- 103/min, RR- 28/min and BP- 94/63 mm of Hg. Clinical examination of the respiratory system was normal. Abdomen was distended, liver was palpable 3cm below right costal margin.CBP revealed normocytic normochromic picture with normal platelet count. CRP level was 10.7 mg/L. BUN, S. creatinine and S. electrolytes were within the normal range. Rapid tests for malarial antigen, HBsAg and anti-HCV antibodies were negative. The liver enzymes were raised (SGOT-993U/Land, SGPT -867U/L). S. bilirubin was 3 mg/dl, PT 18 & INR was 1.4. APTT was normal. USG showcased hepatomegaly with gall bladder edema and ascitis. A provisional diagnosis of viral hepatitis was made.
Repeat total bilirubin was 5.1 mg/dl. The patient developed cough and respiratory distress The X-ray revealed pleural effusion. Repeat USG showed pleural effusion with right lung collapse and ascites. Blood ammonia was raised (337.6μg/L). Repeat CBP showed increased cell count and thrombocytosis.

Serum was outsourced for anti-HAV IgM and anti-HEV IgM ELISA (MP Diagnostics) and both were positive.CUE was normal. A final diagnosis of HAV and HEV induced viral hepatitis was made.

The patient was treated with ceftazidime, vancomycin, metronidazole, piperacillin + tazobactum, ofloxacin, pantoprazole, vitamin K, aceytylcysteine injection, liv 52, levolin nebulization, lasilactose and hepatinic. The child totally recovered from the illness and was discharged from the hospital on the 09/12/14.


Several studies on the acute viral hepatitis (AVH) and acute hepatic failure (AHF) available from India and abroad have reported varying prevalence of co-infection with hepato-tropic viruses (HAV and HEV) in children and adults. 3 6.18% of children and 8.33% of adults had AVH whereas 13.04% of children and 12.5% of adults had AHF respectively. 3 Similarly, Northern Indian study reported increased percentage of HAV induced AVH in adults (26.61% presently vs. 8% previously) combined with decreased percentage in children (27.27 presently vs. 37.5to 64% previously) along with paradoxical increase in the overall incidence of HAV infection. 4 It also stated that there was an indication towards the epidemiological shift of HAV infection from the children to adults with rise in HAV prevalence. 3 As per Karnataka study, 11.5% of individuals had the dual infections with HAV and HEV 1 whereas the other study revealed higher percentage (49%). 5 Dual infections did not affect the prognosis of the patients, they improved after symptomatic treatment. 6 A very low incidence of coexistence of HAV and HEV is seen in Korean population. 7

In our study, anti-HAV IgM and anti-HEV IgM were tested by ELISA. Both were reactive for anti-HAV IgM and anti-HEV IgM. As per Korean study, comparative testing of anti HEV using two different ELISA kits showed markedly discordant results for anti-HEV IgM positivity. Coexistence of anti-HEV IgM measured by Gene labs ELISA kits in the settings of HAV appears to yield false positive result in the non endemic areas of HEV infection. 7 Whereas as per Cuban study, the higher positivity was observed for anti-HAV IgM than anti-HEV IgM. 8

In the Chinese study, Elisa was considered to have the lower sensitivity in comparison with RNA detection. 9, 10 For positive cases of HEV, there was concordance of 77.2 % between nested RT PCR and IgM ELISA whereas agreement between them for negative cases was 80.9%. Recombinant proteins derived from major epitopes of open reading frames (ORF2 and ORF3) of HEV are being used in Elisa commercial kits (Gene labs) for the detection of IgM and IgG. 11 Different epitopes used by different kits might have resulted in different percentage of the positivity of documented cases. 9, 11 Similar results were documented by china study due to use of the different envelope antigens from the different genotypes and subtypes. Furthermore, the antigens derived from the same genotypes and/or subtypes of HEV expressed different expression system displayed significant difference. 9

In our study, serum was not subjected to RNA detection. As per Chinese study, the total agreement between IgM and the nested PCR was 80.9% 9 whereas the positivity for the detection of HEV RNA was lower than ELISA (HEV IgM) in few cases .So it was presumed that it might be due to the short the period of viremia and the early phase of the disease which might have misdiagnosed the cases. 9


Though the prevalence of HAV is much higher than HEV, the most common co-infection of HAV with HEV (11.5%) mandates the screening of the both hepatotrophic agents. Hence always test for HEV IgM if HAV IgM is positive and vice versa. This case presentation will be useful for planning of the future vaccination strategies and better sanitation program in our country. Rapid IgM test and conventional ELISA are useful for diagnosis of acute hepatitis caused by HAV and HEV. RNA detection would be helpful for early diagnosis.

This case report highlights the better hygienic principles practiced by the children as the dual infection with HAV and HEV has become a rare finding in pediatric patients at our hospital


  1. Joon A, Rao P, Shenoy SM et al. Prevalence of HAV and HEV in the patients presenting with acute viral hepatitis. Indian J Med Microbiol 2015;33:S102-5.
  2. Rao P, Shenoy MS, Baliga S et al. Prevalence of HAV and HEV in the patients presenting with acute viral hepatitis. Bio Med Central Inf Dis 2012;12:P30.
  3. Jain P, Prakash S, Gupta S et al. Prevalence of HAV, HBV, HCV, HDV and HEV as causes of acute viral hepatitis in north India: A hospital based study. Indian J Med Microbiol 2013;31:261-265.
  4. Batra Y, Bhatkal B, Oiha B et al. Vaccination against hepatitis A virus may not be required for school children in northern India: Results of a sero-epidemiological survey. Bull World Health Organ 2002;80:728-31.
  5. Al-Naaimi AS, Turkey AM, Khaleel HA et al. Predicting acute viral hepatitis serum markers (A and E) in patients with suspected acute viral hepatitis attending PHC in Baghdad: A one year cross sectional study .Glob J Health Sci 2012;4:172-83.
  6. Radhakrishanan S, Raghuram S, Abraham P et al. Prevalence of enterically transmitted hepatitis viruses in patients attending a tertiary health care centre south India. Indian J Pathol Microbiol 2000:43:433-6.
  7. Jang JH, Jung YM, Kim JS et al. Coexistence of IgM anti-hepatitis A virus and IgM anti-hepatitis E virus in acute viral hepatitis :A prospective ,multicenter study in Korea. J Viral Hepatitis 2011;e408-e414.
  8. Rodriguez Lay Lde, Quintana A, Villalba MC et al. Dual infections with HAV and HEV viruses in outbreaks and in sporadic clinical cases: Cuba 1998-2003. J Med Virol 2008;80:798-802.
  9. Min Liu, Yili Chen, Zhengyu Shen et al. Comparative clinical study on diagnostic detection of HEV between nested PCR and serological tests. Afr J Microbiol Res 2013;7:4801-4805.
  10. Favorov MO, Khudyakov YE, Fields HA et al. EIA for detection of antibody to HEV based on synthetic peptides. J Virol Methods 1994;46:237-50.
  11. Hsiao Ying Chen, Yang Lu, Teresa H et al. Comparison of a new immuno-chromatographic test to Elisa for rapid detection of immunoglobulin M antibodies to hepatitis E virus in human Clin Diagn Lab Immunol 2005;12:593-8.


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