A four-year-old boy was diagnosed with acute lymphoblastic leukemia in February 2011. Thereafter, he received a scheduled chemotherapy plan of 2 - 2.5 years. After cycles of chemotherapy, he received erythrocytes, platelets and fresh blood, due to chemotherapy-induced cytopenia. In early August, the boy complained of anorexia, nausea, and fatigue. Elevated levels of transaminases were detected in his serum. Serological tests for hepatitis A, B, C, and CMV had negative findings, whereas anti-HEV IgM was found to have positive results (Table 1). At admission on the 8th October, his serum values were as follows; alanine aminotransferase (ALT) 540 U/L (normal: < 45), aspartate aminotransferase (AST) 259 U/L (normal: < 50), total bilirubinemia (TBIL) 27.6mumol/L (normal: < 17.5 mumol/L), alkaline phosphatase (ALP) 157 U/L (normal: 45 - 135), c-glutamyltransferase (GGT) 97 U/L (normal: 10 - 47). Anti-HEV IgM anti-HEV IgG had positive results, but both were at low levels in terms of the ELSIA OD values of 0.27 and 0.22, respectively. HEV RNA was detected in the serum using RT-nested PCR. The HEV genotype was determined to be 4d by sequencing and analyzing the PCR amplicon (GenBank accession number: KF691589) (Figure 1). Physical examination at diagnosis of the HEV infection had normal findings, no jaundice or hepatosplenomegaly was observed. Color Doppler Ultrasound showed that the liver was normal in size and structure. However, when the patient insisted on leaving on November 10th for the following scheduled chemotherapy, HEV RNA in the serum had negative results, but the transaminases did not normalize; ALT 118 U/L, AST 94U/L, ACP 190 U/L, GGT 97 U/L.
In May 2013, twenty months later, the patient returned to our hospital for the treatment of hepatitis, after completing the latest intensive chemotherapy. Pathological values were obtained as follows; ALT 523 U/L, AST 822 U/L, ALP 527 U/L, GGT 352 U/L,serum albumin (ALB) 36.2 g/L (normal: 37-53 g/L), and TBIL 29.7 mumol/L. Anti-HEV IgM and IgG had positive results in the serum, and HEV RNA was also positive, with high levels up to 3.6 x 106 Geq/mL. The liver was still normal in size and structure by Color Doppler Ultrasound detection. The sequence of the 304 bp amplicon in the HEV ORF2 region was identical to that of the isolate obtained in 2011. It was most likely as a persistent HEV infection. Two months later, the HEV RNA levels had decreased in the serum to below detection limits, while the ALT level was still out of the normal range and anti-HEV IgM remained positive (Table 1).