Association between hepatitis E and Guillain-Barre syndrome

Last Updated: 2016-11-07

By Will Boggs MD

NEW YORK (Reuters Health) - Hepatitis E virus (HEV) infection is occasionally associated with Guillain-Barre syndrome (GBS), researchers from Belgium report.

"Although HEV has been known for a very long time, its immune-mediated neurological complications, such as GBS and neuralgic amyotrophy, are only relatively recently described," Dr. Philip Van Damme from University Hospitals Leuven told Reuters Health by email.

HEV, a non-enveloped RNA virus, is the most frequent cause of viral hepatitis worldwide and is endemic in one-third of the world population.

Dr. Van Damme and colleagues retrospectively assessed the prevalence of acute HEV infection in 88 patients with GBS or a variant of GBS.

Six patients (8%) had positive anti-HEV IgM, including four (67%) with alanine aminotransferase (ALT) levels more than 1.5 times the upper limit of normal. Thirteen patients (18%) had positive IgG serology for HEV.

Two of the six patients with positive IgM results also had positive serologic results for CMV or EBV IgG and IgM.

The phenotypes of GBS in HEV-positive patients varied widely, from classic GBS to a pharyngeal-cervical-brachial variant and a sensory ataxic variant, according to the November 7th JAMA Neurology online report.

All six patients with HEV IgM antibodies tested negative for anti-ganglioside and anti-sulfatide antibodies.

"A preceding HEV infection is frequently associated with GBS or GBS variants (more than 5% of patients), certainly if elevated liver enzymes are present (19% of such patients, second cause after CMV)," Dr. Van Damme said.

"There are currently no specific treatments for HEV-associated GBS and therefore the testing for HEV has no therapeutic implications," he added.

"Guillain-Barre syndrome is not the only neurological syndrome associated with HEV infection," write Dr. Kenneth L. Tyler and Dr. Daniel M. Pastula from University of Colorado School of Medicine, Aurora, in a related commentary. "A series of recent studies have provided increasingly convincing data linking HEV infection with neuralgic amyotrophy (also known as brachial neuritis or Parsonage-Turner syndrome) and less frequently with mononeuritis multiplex, meningoradiculitis, and myositis. More studies are needed to determine the role of HEV in these syndromes and whether they share pathogenetic mechanisms with GBS associated with HEV."

Dr. Harry R. Dalton from Royal Cornwall Hospital Trust, Truro, UK, an expert on HEV, told Reuters Health by email, "They have not considered the issue of re-infections with HEV as a possibility in patients with GBS. Reinfection occurs quite commonly (10% of cases in a recent German study). Reinfections with HEV are very hard to diagnose, especially in patients treated with IVIG, as often the only clue to the diagnosis is a rising anti-HEV IgG."

He expressed other concerns about the study. "They used the wrong serological assay, which underestimates seroprevalence by up to 50%, and may have more false positives," he said. "They did not do HEV PCR on all the patients, irrespective of the serology results; and they had no controls."

SOURCE: http://bit.ly/2fLGecC

JAMA Neurol 2016.