Occult rat hepatitis E virus infection as a cause of cirrhosis and posttransplant recurrence: Insights into the role of metagenomics

We report the case of a kidney-transplant recipient (2011) who developed persistent elevation of liver enzymes beginning in 2015. Extensive investigations including standard hepatitis E virus PCR failed to identify a cause. In 2019, she developed decompensated cirrhosis and underwent liver-kidney transplantation in 2021. Posttransplant, liver function tests remained abnormal. Given suspicion of an unidentified pathogen, metagenomic next-generation sequencing was performed on the graft and identified rat hepatitis E virus. Retrospective testing of native liver and serum samples confirmed infection since 2015. Ribavirin therapy resulted in normalization of liver enzymes and viral clearance.