Abstract Introduction Hepatitis E virus (HEV) is an under-recognized cause of acute and chronic hepatitis in solid-organ transplant recipients. While HEV is typically foodborne, transmission can occur through blood products and organ transplantation, and immunosuppressed patients are at risk for persistent viremia. We present a case of early post-lung transplant HEV infection, highlighting diagnostic challenges and management considerations. Case Description A 63-year-old man with a history of tonsillar squamous cell carcinoma treated with chemoradiation developed radiation-induced pulmonary fibrosis and respiratory failure. Due to severe dysphagia and aspiration risk after radiation, a gastrostomy tube was placed two months before transplant. He ultimately required mechanical ventilation then veno-venous extracorporeal membrane oxygenation support (ECMO) as a bridge to bilateral lung transplantation, where he required intraoperative ECMO support. He was extubated on postoperative day (POD) 3 and later transitioned to inpatient rehabilitation. Around POD 90, he developed fatigue, fevers, and watery diarrhea. Laboratory evaluation demonstrated newly elevated aminotransferases, aspartate aminotransferase 618 U/L and alanine aminotransferase 360 U/L. Mycophenolate mofetil, azithromycin, voriconazole and trimethoprim-sulfamethoxazole were paused due to concern for drug-induced liver injury. Cytomegalovirus, Ebstein-Barr virus, adenovirus, and hepatitis A/B/C polymerase chain reaction (PCR) testing was negative, and abdominal ultrasound was unremarkable.Given persistent transaminitis, hepatology was consulted. HEV testing was sent, and viral PCR measured 3,341,764, IU/mL, confirming acute infection. The patient exclusively used his gastrostomy tube for enteric access and had no recent travel, suggesting acute infection from blood transfusion, organ donor, or water contamination versus progression of a chronic infection. Immunosuppression was reduced and ribavirin initiated, leading to clinical and biochemical improvement. The patient is over one-year post-transplant and doing well with excellent graft function. Discussion HEV is an emerging pathogen in the post-transplant setting and should be considered in transplant recipients with unexplained hepatitis. Lung transplant patients are particularly vulnerable due to high transfusion exposure and immunosuppression. Diagnosis requires specific HEV PCR testing, which is not included in routine viral surveillance. Early recognition can prevent chronic infection and hepatic dysfunction, which can occur in up to 60% of immunosuppressed hosts without intervention. Further investigation is warranted to evaluate the potential benefit of HEV screening in future solid organ transplant recipients. This abstract is funded by: None
Phillips et al. (Fri,) studied this question.