Co-infection of Hepatitis A and E With Atypical Manifestation: A Case Report

Hepatitis A virus (HAV) and hepatitis E virus (HEV) are common causes of acute viral hepatitis in developing countries where inadequate sanitation and contaminated water supplies facilitate fecal-oral transmission. Although both infections are usually self-limiting, co-infection may result in atypical presentations and pose diagnostic challenges. We report the case of a previously healthy 14-year-old girl who presented with a 5-day history of nausea, vomiting, and anorexia, followed by sudden-onset jaundice and dark urine. She denied fever, abdominal pain, pruritus, bleeding manifestations, or altered mental status. Physical examination revealed marked icterus without hepatosplenomegaly or stigmata of chronic liver disease. Laboratory investigations demonstrated significant hyperbilirubinemia and elevated liver transaminases. Serological testing confirmed acute HAV and HEV co-infection with positive anti-HAV IgM and anti-HEV IgM antibodies. Abdominal ultrasonography showed a normal-sized liver with altered echogenicity and a characteristic "starry sky" appearance, along with gallbladder wall thickening without calculi or sludge. The patient received supportive treatment, including intravenous fluids, antiemetics, and symptomatic care. Her clinical condition improved steadily, with resolution of symptoms and progressive normalization of liver function tests during hospitalization. She was discharged in stable condition and remained asymptomatic at 14-day follow-up, with complete biochemical and radiological recovery. This case highlights that HAV-HEV co-infection can present with isolated jaundice and minimal systemic symptoms despite significant hepatic involvement. Recognition of characteristic imaging findings and timely serological evaluation can facilitate early diagnosis. Favorable outcomes can be achieved with supportive management, while prevention through vaccination, safe drinking water, and improved hygiene remains essential in endemic regions.