Hepatitis E Viral Association with Autoimmune Hepatitis: A Viral Trigger or Cross-Reactivity

Autoimmune hepatitis (AIH) is a chronic disease characterized by hepatocellular inflammation and destruction. Its pathogenesis remains unclear. Current evidence suggests that environmental factors, including viral infections, are implicated as possible triggers. We present a case of a 36-year-old lady with systemic lupus erythematosus who presented with abdominal pain, nausea, vomiting, and jaundice. She was initially diagnosed as acute hepatitis E virus (HEV) infection based on positive serology, but she did not improve with conservative management. Subsequently, she underwent liver biopsy that showed features characteristic of AIH. We discuss the role of HEV as a possible trigger of AIH. We also highlight the possibility of cross-reactivity between liver antigens and HEV as an explanation for the positive HEV serology in AIH. We explore the management options of cases in which both acute HEV infection and AIH coexist, which might be challenging as there is no current consensus whether to start immunosuppressive therapy or to manage such cases conservatively. Moreover, we discuss previous similar cases in which different lines of management were chosen.