Home Diagnostics and importance of hepatitis E virus infections
Article Open Access

Diagnostics and importance of hepatitis E virus infections

  • Andreas Osterman EMAIL logo , Hans Nitschko , Josef Eberle and Hartmut Campe
Published/Copyright: December 8, 2015
Download Article (PDF)
Become an author with De Gruyter Brill
Submit Manuscript Author Information
LaboratoriumsMedizin
From the journal LaboratoriumsMedizin Volume 39 Issue s1

Abstract

The diagnosis of hepatitis E virus (HEV) infections has been recently substantially facilitated by the introduction of a whole range of new different virological assays. The increasing appearance of sporadic cases of acute hepatitis E in Germany directed the focus toward the zoonotic transmission route of the virus. The recognition of HEV genotypes differing in virulence and in pathogenic potential is not only relevant for epidemiology and the course of the disease, but also for the development and choice of diagnostic tools. A broad variety of enzymatic and protein-based assay formats detecting anti-HEV IgG or IgM antibodies directed against the different genotype variants of HEV is available (ELISA, LIA, Western blot); however, sensitivity and specificity of these assays differ notably. Today’s state-of-the art technology that permits fast and reliable assay-based confirmation of HEV infections is PCR. The newly developed commercially available PCR kits will detect all four human pathogenic HEV genotypes. Further subdivision and discrimination can be achieved by sequencing, although this approach is only reasonable in the setting of specific epidemiological demands. Detection of viral antigens, cell culture, and T-cell assays are of no practical importance in a routine diagnostic setting. New insight into the pathogenesis and its clinical relevance for defined groups of patients (immunosuppressed) as well as the implementation of specific antiviral and prophylactic therapies (vaccination) will further challenge the performance of existing assay formats and increase the technical demands for the diagnostic laboratory.

Reviewed Publication:

Weber B.

Keywords: antibody test; diagnostic methods; hepatitis E virus; RT-PCR; virus detection

Introduction

As a result of increased attention and new, improved diagnostic methods, the number of reports received by the Robert Koch Institute about acute hepatitis E virus (HEV) infections has been rising every year. Epidemiological studies suggest, however, that not every symptomatic hepatitis E disease in Germany is detected and reported, and that the majority of infections are subclinical in their progression. Following oral intake of particles, and depending on the genotype and pre-existing conditions, the virus can cause acute or chronic hepatitis. Acutely ill patients exhibit typical clinical signs of liver inflammation, such as fever, nausea, upper abdominal pain and jaundice. Until a few years ago, HEV infections in Germany were deemed a rare disease, exclusively linked to travel history. Today we know that most of the infections occurring are acquired autochthonously [1, 2].

This paper is to reveal the current state of knowledge about hepatitis E virus infections and the options provided by virological diagnostics.

Genome organization and variability

The hepatitis E virus is a small, non-enveloped, single-stranded (+) RNA virus. The genome of the virus is formed by approx. 7200 nucleotides, and it comprises three open reading frames (ORFs) [3]. ORF1 is the largest reading frame and encodes a functional polyprotein, which consists, among other domains, of a methyltransferase, protease, helicase and polymerase [4]. ORF2 encodes the viral capsid protein. ORF3 is the smallest reading frame, and many different functions are attributed to it [5] (Figure 1). Taxonomically, the hepatitis E virus is currently assigned to the Hepeviridae family as the only species of the Hepevirus genus. In total, the four human pathogenic genotypes (HEV 1-4) are divided into (at least) 24 subtypes [7]. This heterogeneity plays a role on several levels: Initial studies show that the variable region V of the HEV genome seems to affect the tropism and pathogenicity of individual genotypes [8, 9]. On the nucleotide level, the variability (up to 25% difference between the genotypes) poses a challenge in the development of NAT test systems, which ideally should cover all genotypes with the same sensitivity. This genetic variability also creates some differences in the protein sequence, resulting in a genotype-specific antigen reaction in patient samples of serological tests (see below).

Figure 1: Overview of the genomic structure of the hepatitis E virus (example of nucleotide positions (nt) according to the genebank entry L08816 [6]).
Figure 1:

Overview of the genomic structure of the hepatitis E virus (example of nucleotide positions (nt) according to the genebank entry L08816 [6]).

Hepatitis E in Germany – a zoonotic disease

Knowing about the different characteristics of HEV genotypes is also very important in the diagnosis and treatment of hepatitis E. One of the main differences of HEV genotypes is their transmission. Genotypes 1 and 2 infect several million people in Asia and Africa every year [10]. Both genotypes are transmitted via the fecal-oral route with contaminated water and from person to person. The seroprevalence in the tropical areas of Africa and Asia is estimated to be approximately 50% [11]. In Germany it is especially genotype 3 that causes infections (autochthonous cases). Genotypes 3 and 4 have been detected both in humans and in pigs. The consumption of undercooked pork (e.g. sausages) and contact with infected animals are considered the most frequent transmission routes [12, 13]. Person-to-person transmission is irrelevant for genotype 3. Thus, a genotype 3 infection represents a zoonotic disease, endemic in Germany.

Epidemiology

The global burden of disease is concentrated in the tropical areas of Africa and Asia, with over 3 million people affected each year (genotype 1 and 2 infections). There are regular epidemic infection clusters. Mortality is reported to be about 2%. A higher risk of a fulminant progression of genotype 1 and 2 infections affects pregnant women and patients with a compromised liver function [9, 14].

In 2014, 670 HEV cases were reported to the Robert Koch Institute [15]. The majority of these genotype 3 infections were acquired in Germany (2013: 84%) (Figure 2). Children are less likely to become ill; fulminant infection progression after genotype 3 infections is the exception also for pregnant women. Seroprevalence studies with newer antibody tests (see below) have found in approximately 17% of adults in Germany anti-HEV IgG antibodies as signs of an acquired – albeit often asymptomatic – HEV infection [16]. This corresponds to estimated 250,000 new HEV infections annually. Seroprevalence, calculated incidence and reporting statistics give rise to the well-founded assumption that less than one in 100 HEV infections is clinically apparent in Germany.

Figure 2: Reporting statistics of hepatitis E cases in Germany (Source: Infectious Disease Epidemiology yearbooks, Robert Koch Institute).
Figure 2:

Reporting statistics of hepatitis E cases in Germany (Source: Infectious Disease Epidemiology yearbooks, Robert Koch Institute).

Symptomatology

The vast majority of HEV infections are asymptomatic.

Typical signs of a symptomatic HEV infection after an incubation period of up to 60 days include: fever, fatigue, nausea/vomiting, jaundice, itching and upper abdominal pain with known biochemical changes (above all, increases in transaminases and bilirubin, as well as in alkaline phosphatase and gamma GT) [1, 14]. Atypical symptoms such as arthralgia and myalgia and extrahepatic manifestations (especially neurological symptoms such as Guillain-Barré syndrome) have been reported [17]. Hepatitis E is usually a harmless and self-limiting infection.

Chronic HEV infections are described in immunocompromised patients after organ and stem cell transplantation, while they are rare in HIV patients [9]. Currently, the chronification of HEV infection is defined as a virus persistence of more than 3 months. It can lead to liver cirrhosis after a short period of time [18, 19]. Chronic progressions are described only for genotypes 3 and 4, and not for genotypes 1 and 2.

Blood donation

There is no definitive conclusion yet about the possible transmission of HEV through blood transfusions. Due to the “limited pathogen virulence”, HEV testing is deemed unnecessary for immunocompetent patients, but the possible chronification of the infection is seen as a problem in immunocompromised patients (following organ or stem cell transplantation) [20]. This is expected to be reevaluated once new research findings on the benefit of the HEV testing of blood products are available [21].

Diagnostic methods

Patient history, clinical and laboratory methods do not allow for a clear differentiation of HEV infections from hepatitis cases of a different origin. Therefore, the diagnosis is based on various direct and indirect detection methods. In general, the diagnosis of an HEV infection is asserted serologically. Molecular detection methods (PCR) can be used for confirmation, for the quantification of the viral load and for genotyping. The increasing report numbers confirm that it is necessary to consider the possibility of an HEV infection in the presence of corresponding symptoms and once other causes have been ruled out.

Antibody detection

Methods

Tests for HEV-specific antibodies in the patient serum are available commercially today in various test formats. Common methods are: Western blot, line immunoassay (LIA), enzyme linked immunosorbent assay (ELISA) or enzyme immunoassay (EIA) [22]. Most of these tests are based on recombinant antigens of ORFs 2 and 3, which, depending on the manufacturer, utilize different genotypes. In particular, the C-termini of the viral proteins encoded in ORF2 and 3 have been shown to be highly immunogenic [6]. Confusion arises from the marked differences in diagnostic sensitivity and specificity of different hepatitis E ELISAs and immunoblots [23]. Studies in Germany reflect these problems as well, as seroprevalence estimates vary depended on the test manufacturer [24] (Table 1). While only one serotype is postulated for human pathogenic hepatitis E viruses, there is still indication of different, genotype-specific antibody reactions. Several studies from Europe and Asia suggest that the genotype of the antigen used may have a significant influence on the sensitivity of a test, and therefore it is recommended that the local distribution of HEV genotypes should be taken into account when selecting a test kit [23, 27].

Table 1

Overview of IgG seroprevalence rates detected by different commercial hepatitis E virus antibody assays.

NameManufacturerSeroprevalence
Southern GermanyaSouthern EnglandbSouthern Francec
MP Diagnostik HEV IgG ELISAGenelabs technology4.5%3.6%16.6%
Axiom Diagnostics HEV IgG EIAWantai29.5%16.2%52.5%
RecomLINE HEV IgG immunoblotMikrogen18%––

aWenzel et al. [24], bBendall et al. [23], cMansuy et al. [25, 26].

Antibody classes

The detection of IgM and IgG is suitable for the diagnosis of a new or past HEV infection in immunocompetent patients. In combination, a sensitivity of up to 99% can be reached for an acute HEV infection. IgM antibodies are detectable shortly after the onset of symptoms, and subsequently for a period of 3–5 months. Shortly after the first detection of IgM, the IgG titer increases as well and can then be detected as a titer indicative of a past infection for several years [14, 28] (Figure 3). A solitary IgM should be verified or supplemented by a PCR analysis, since IgM is considered a very sensitive marker of acute hepatitis E, but its specificity is still subject to critical discussions in the literature [29, 30]. In the context of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections, false positive results for anti-HEV IgM antibodies are frequently observed [31]. The analysis of IgA has been proposed in the literature as an alternative to IgM or as a possible addition to serological diagnosis [32]. This is to increase specificity and allow for a new HEV infection to remain detectable over a longer period of time. However, commercial test systems available up to now can be used only to determine antibodies of the IgG and IgM classes.

Figure 3: Schematic of a hepatitis E infection (adapted from Krain et al. [9]).
Figure 3:

Schematic of a hepatitis E infection (adapted from Krain et al. [9]).

Nucleic acid diagnostics

Real-time PCR

Thanks to new sensitive PCR methods, the HEV genome detection succeeds in around 90% of all acute HEV infections. HEV-RNA can be detected in blood 2–4 weeks and even up to 6–8 weeks in stool after the onset of symptoms [28]. The success of genome detection through NAT detection systems still requires that samples of viral RNA be transported correctly and that samples be taken at the appropriate time. The nucleic acid of the hepatitis E virus can even be detected in biopsy material. This might play a role in the future, for example in diagnosing chronic hepatitis E after transplantation and immunosuppression [33]. Modern PCR systems based on real-time methods have been optimized for several genotypes. In some cases, they can detect the HEV genome in patient material also quantitatively [34]. This specific issue is addressed by several commercially available test kits (Table 2), but the use of so-called “in-house” PCR systems is widespread. Inter-laboratory testing of all samples and methods shows, overall, an average rate of >92% in terms of correct test results. However, it seems that commercial assays perform slightly better than in-house systems. This high success rate also applies to samples with rather low virus concentrations between 103 and 104 IU/mL [35]. A “loop-mediated isothermal amplification”-based test has been developed for countries with limited resources [36]. Given the various genotypes, there are differences in sensitivity and, thus, also quantification in a large number of PCR assays used. A WHO standard (genotype 3), which was released recently, represents an important step towards the harmonization and comparability of PCR assays used throughout the world [37]. The question whether genotype-specific detection and/or type differentiation could become relevant outside the scope of epidemiology is hard to answer at this point.

Table 2

Overview of commercial hepatitis E virus PCR detection kits.

Detection kitManufacturerSpecifications (according to manufacturer)
Real Star® HEV RT-PCR KitAltona DiagnosticsCE-IVD, detection limit: 0.31 IU/μL eluate
AmpliCube HEVMikrogenCE-IVD, detection limit: >104 copies/mL: 100%
COBAS TaqScreen HEVRocheDetection HEV 1–4, detection limit: 19 IE/mL
Hepatitis E Virus AssayCeeram ToolsDetection limit: >1–10 copies/PCR solution
HEV Real Time-PCR Kit IVDGeno-Sen’sDetection limit: 80 copies/mL (for RotorGene)

Sequencing

The sequencing of the hepatitis E virus genome provides an insight into the epidemiology of hepatitis E. Thus, it has been possible to map the geographical distribution of the genotypes [7] and confirm transmission from pigs to humans in some cases of autochthonous HEV infections [13]. The sub-genotyping and phylogenetic analyses necessary to address these questions are mainly performed in laboratories with certain epidemiological specializations.

Special diagnostics

Antigen detection

Studies done in Asia have shown that the antigen detection from serum and stool constitutes a sensitive method during the viremic phase of an acute hepatitis E. Especially when resources are limited, or in outbreak situations, this method may be a diagnostic alternative to genome detection [38]. To what extent this can be applied to tests in industrialized countries with HEV infections of a different genotype and different epidemiology, and whether it is suitable for routine processes (such as for blood donations in Germany), has not been revealed yet [21, 39].

Histology

In clarifying an unclear case of hepatitis, a liver biopsy may sometimes be taken, which, to an experienced pathologist, may indicate the presence of an HEV infection. Immuno-histochemical staining of HEV antigen (especially the capsid antigen) has been described experimentally, but has not yet found its way into routine pathological diagnostics – particularly, as rising awareness of hepatitis E has often caused diagnoses to be made more quickly by serological or molecular-biological tests [40].

Virus-specific T-cells

Meanwhile it also possible to detect hepatitis E virus-specific T-cells in patients with a new infection and to correlate their activation and cytokine release with the progression of the condition [9, 41]. The extent to which these findings may be diagnostically relevant to the prognosis for immunocompromised patients has yet to be evaluated.

Direct virus detection

Experimentally, the virus can be detected directly following the inoculation and infection of primates or pigs. Recently it has also become possible to grow the virus in cell culture (PLC/PRF/5, A549) deploying positive patient material [42, 43]. However, these cell culture systems are not used for diagnostic purposes, but rather help explore the molecular biology of the virus and possible treatments options.

Treatment and prevention

Clinically apparent HEV infections are treated purely on the basis of symptoms. A collection of case reports, recently published by Kamar et al. [44], provides proof of the possible HEV elimination (genotype 3) in connection with ribavirin therapy in the case of organ transplant recipients. Pischke et al. [45] have confirmed the effectiveness of a ribavirin therapy in connection with HEV infections. Therefore, drug treatment should also be considered in the rare cases of HEV-associated, fulminant liver failure.

In recent years, a genotype 1 subunit vaccine against HEV was developed and approved in China (Hecolin®) [46]. The WHO Strategic Advisory Group of Experts on Immunization (SAGE) has not yet issued a general recommendation for the use of the vaccine; there have not been sufficient studies yet to assess its benefit. Only in the case of infection clusters (outbreaks) can the use of the HEV vaccine be considered, according to SAGE [47].

Conclusions

The data collected in recent years on the hepatitis E virus suggest that there are considerable variations between the different hepatitis E virus genotypes with respect to epidemiology, transmission and clinical progression (Table 3).

Table 3

Varying significance of different HEV genotypes.

Genotypes 1 and 2Genotype 3 (and 4)
SpreadTropics of Asia and AfricaWestern industrialized countries (genotype 4 also sporadically in Asia)
TransmissionDrinking waterPork
Seroprevalence50%17% (Germany)
Clinical progressionAsymptomatic/acuteAsymptomatic/acute/chronic
Risk groupsPregnant women – fulminant progressionImmunocompromised/chronically ill patients – chronic progression

This genetic heterogeneity was also taken into account during the further development of immunological and molecular-biological HEV test methods. This will now allow one to detect the infection with certainty, provided one keeps in mind the differential diagnosis of hepatitis E.

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Correspondence: Dr. med. Andreas Osterman, Max von Pettenkofer-Institute, Virology, Pettenkoferstrasse 9a, 80336 Munich, Germany, Tel.: +49-89-2180-72835, Fax: +49-89-2180-72873

References

1. Pischke S, Behrendt P, Bock CT, Jilg W, Manns MP, Wedemeyer H. Hepatitis E in Germany–an under-reported infectious disease. Dtsch Arztebl Int 2014;111:577–83.10.3238/arztebl.2014.0577Search in Google Scholar

2. Robert-Koch-Institut, Berlin. 6. Infektionsepidemiologisches Jahrbuch meldepflichtiger Krankheiten für 2013. 2014.Search in Google Scholar

3. Tam AW, Smith MM, Guerra ME, Huang CC, Bradley DW, Fry KE, et al. Hepatitis E virus (HEV): molecular cloning and sequencing of the full-length viral genome. Virology 1991;185:120–31.10.1016/0042-6822(91)90760-9Search in Google Scholar

4. Koonin EV, Gorbalenya AE, Purdy MA, Rozanov MN, Reyes GR, Bradley DW. Computer-assisted assignment of functional domains in the nonstructural polyprotein of hepatitis E virus: delineation of an additional group of positive-strand RNA plant and animal viruses. Proc Natl Acad Sci USA 1992;89:8259–63.10.1073/pnas.89.17.8259Search in Google Scholar PubMed PubMed Central

5. Geng Y, Yang J, Huang W, Harrison TJ, Zhou Y, Wen Z, et al. Virus host protein interaction network analysis reveals that the HEV ORF3 protein may interrupt the blood coagulation process. PLoS One 2013;8:e56320.10.1371/journal.pone.0056320Search in Google Scholar PubMed PubMed Central

6. Osterman A, Vizoso Pinto MG, Haase R, Nitschko H, Jager S, Sander M, et al. Systematic screening for novel, serologically reactive Hepatitis E Virus epitopes. Virol J 2012;9:28.10.1186/1743-422X-9-28Search in Google Scholar PubMed PubMed Central

7. Lu L, Li C, Hagedorn CH. Phylogenetic analysis of global hepatitis E virus sequences: genetic diversity, subtypes and zoonosis. Rev Med Virol 2006;16:5–36.10.1002/rmv.482Search in Google Scholar PubMed

8. Johne R, Reetz J, Ulrich RG, Machnowska P, Sachsenroder J, Nickel P, et al. An ORF1-rearranged hepatitis E virus derived from a chronically infected patient efficiently replicates in cell culture. J Viral Hepat 2014;21:447–56.10.1111/jvh.12157Search in Google Scholar PubMed

9. Krain LJ, Nelson KE, Labrique AB. Host immune status and response to hepatitis E virus infection. Clin Microbiol Rev 2014;27:139–65.10.1128/CMR.00062-13Search in Google Scholar PubMed PubMed Central

10. Rein DB, Stevens GA, Theaker J, Wittenborn JS, Wiersma ST. The global burden of hepatitis E virus genotypes 1 and 2 in 2005. Hepatology 2012;55:988–97.10.1002/hep.25505Search in Google Scholar PubMed

11. Jia Z, Yi Y, Liu J, Cao J, Zhang Y, Tian R, et al. Epidemiology of hepatitis E virus in China: results from the Third National Viral Hepatitis Prevalence Survey, 2005–2006. PLoS One 2014;9:e110837.10.1371/journal.pone.0110837Search in Google Scholar PubMed PubMed Central

12. Wichmann O, Schimanski S, Koch J, Kohler M, Rothe C, Plentz A, et al. Phylogenetic and case-control study on hepatitis E virus infection in Germany. J Infect Dis 2008;198:1732–41.10.1086/593211Search in Google Scholar PubMed

13. Wenzel JJ, Preiss J, Schemmerer M, Huber B, Plentz A, Jilg W. Detection of hepatitis E virus (HEV) from porcine livers in Southeastern Germany and high sequence homology to human HEV isolates. J Clin Virol 2011;52:50–4.10.1016/j.jcv.2011.06.006Search in Google Scholar

14. Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, Ijaz S, Izopet J, et al. Hepatitis E. Lancet 2012;379:2477–88.10.1016/S0140-6736(11)61849-7Search in Google Scholar

15. Robert-Koch-Institut, Berlin. Hepatitis-E-Virus-Infektionen aus virologischer Sicht. Epidemiologisches Bulletin Nr. 15. 2015.Search in Google Scholar

16. Faber MS, Wenzel JJ, Jilg W, Thamm M, Hohle M, Stark K. Hepatitis E virus seroprevalence among adults, Germany. Emerg Infect Dis 2012;18:1654–7.10.3201/eid1810.111756Search in Google Scholar PubMed PubMed Central

17. Woolson KL, Forbes A, Vine L, Beynon L, McElhinney L, Panayi V, et al. Extra-hepatic manifestations of autochthonous hepatitis E infection. Aliment Pharmacol Ther 2014;40:1282–91.10.1111/apt.12986Search in Google Scholar PubMed

18. Kamar N, Rostaing L, Legrand-Abravanel F, Izopet J. How should hepatitis E virus infection be defined in organ-transplant recipients? Am J Transplant 2013;13:1935–6.10.1111/ajt.12253Search in Google Scholar PubMed

19. Kamar N, Selves J, Mansuy JM, Ouezzani L, Peron JM, Guitard J, et al. Hepatitis E virus and chronic hepatitis in organ-transplant recipients. N Engl J Med 2008;358:811–7.10.1056/NEJMoa0706992Search in Google Scholar PubMed

20. Juhl D, Baylis SA, Blumel J, Gorg S, Hennig H. Seroprevalence and incidence of hepatitis E virus infection in German blood donors. Transfusion 2014;54:49–56.10.1111/trf.12121Search in Google Scholar PubMed

21. Stellungnahme des Arbeitskreises Blut des Bundesministeriums für Gesundheit. Hepatitit-E-Virus. 2014.Search in Google Scholar

22. Mushahwar IK. Hepatitis E virus: molecular virology, clinical features, diagnosis, transmission, epidemiology, and prevention. J Med Virol 2008;80:646–58.10.1002/jmv.21116Search in Google Scholar PubMed

23. Bendall R, Ellis V, Ijaz S, Ali R, Dalton H. A comparison of two commercially available anti-HEV IgG kits and a re-evaluation of anti-HEV IgG seroprevalence data in developed countries. J Med Virol 2010;82:799–805.10.1002/jmv.21656Search in Google Scholar PubMed

24. Wenzel JJ, Preiss J, Schemmerer M, Huber B, Jilg W. Test performance characteristics of Anti-HEV IgG assays strongly influence hepatitis E seroprevalence estimates. J Infect Dis 2013;207:497–500.10.1093/infdis/jis688Search in Google Scholar PubMed

25. Mansuy JM, Legrand-Abravanel F, Calot JP, Peron JM, Alric L, Agudo S, et al. High prevalence of anti-hepatitis E virus antibodies in blood donors from South West France. J Med Virol 2008;80:289–93.10.1002/jmv.21056Search in Google Scholar PubMed

26. Mansuy JM, Bendall R, Legrand-Abravanel F, Saune K, Miedouge M, Ellis V, et al. Hepatitis E virus antibodies in blood donors, France. Emerg Infect Dis 2011;17:2309–12.10.3201/eid1712.110371Search in Google Scholar PubMed PubMed Central

27. Park HK, Jeong SH, Kim JW, Woo BH, Lee DH, Kim HY, et al. Seroprevalence of anti-hepatitis E virus (HEV) in a Korean population: comparison of two commercial anti-HEV assays. BMC Infect Dis 2012;12:142.10.1186/1471-2334-12-142Search in Google Scholar PubMed PubMed Central

28. Ahmed A, Ali IA, Ghazal H, Fazili J, Nusrat S. Mystery of hepatitis e virus: recent advances in its diagnosis and management. Int J Hepatol. 2015;2015:872431.10.1155/2015/872431Search in Google Scholar PubMed PubMed Central

29. Takahashi M, Kusakai S, Mizuo H, Suzuki K, Fujimura K, Masuko K, et al. Simultaneous detection of immunoglobulin A (IgA) and IgM antibodies against hepatitis E virus (HEV) Is highly specific for diagnosis of acute HEV infection. J Clin Microbiol 2005;43:49–56.10.1128/JCM.43.1.49-56.2005Search in Google Scholar PubMed PubMed Central

30. Tian DY, Chen Y, Xia NS. Significance of serum IgA in patients with acute hepatitis E virus infection. World J Gastroenterol 2006;12:3919–23.10.3748/wjg.v12.i24.3919Search in Google Scholar PubMed PubMed Central

31. Hyams C, Mabayoje DA, Copping R, Maranao D, Patel M, Labbett W, et al. Serological cross reactivity to CMV and EBV causes problems in the diagnosis of acute hepatitis E virus infection. J Med Virol 2014;86:478–83.10.1002/jmv.23827Search in Google Scholar PubMed

32. Osterman A, Vizoso-Pinto MG, Jung J, Jaeger G, Eberle J, Nitschko H, et al. A novel indirect immunofluorescence test for the detection of IgG and IgA antibodies for diagnosis of Hepatitis E Virus infections. J Virol Methods 2013;191:48–54.10.1016/j.jviromet.2013.03.022Search in Google Scholar PubMed

33. Protzer U, Bohm F, Longerich T, Seebach J, Heidary Navid M, Friemel J, et al. Molecular detection of hepatitis E virus (HEV) in liver biopsies after liver transplantation. Mod Pathol 2015;28:523–32.10.1038/modpathol.2014.147Search in Google Scholar PubMed

34. Jothikumar N, Cromeans TL, Robertson BH, Meng XJ, Hill VR. A broadly reactive one-step real-time RT-PCR assay for rapid and sensitive detection of hepatitis E virus. J Virol Methods 2006;131:65–71.10.1016/j.jviromet.2005.07.004Search in Google Scholar PubMed

35. INSTAND e.V.. Bericht zum Ringversuch Gruppe 380 Virusgenom-Nachweis – Hepatitis E Virus. November/Dezember 2014.Search in Google Scholar

36. Lan X, Yang B, Li BY, Yin XP, Li XR, Liu JX. Reverse transcription-loop-mediated isothermal amplification assay for rapid detection of hepatitis E virus. J Clin Microbiol 2009;47:2304–6.10.1128/JCM.00498-09Search in Google Scholar PubMed PubMed Central

37. Baylis SA, Blumel J, Mizusawa S, Matsubayashi K, Sakata H, Okada Y, et al. World Health Organization International Standard to harmonize assays for detection of hepatitis E virus RNA. Emerg Infect Dis 2013;19:729–35.10.3201/eid1905.121845Search in Google Scholar PubMed PubMed Central

38. Majumdar M, Singh MP, Pujhari SK, Bhatia D, Chawla Y, Ratho RK. Hepatitis E virus antigen detection as an early diagnostic marker: report from India. J Med Virol 2013;85:823–7.10.1002/jmv.23529Search in Google Scholar PubMed

39. Vollmer T, Knabbe C, Dreier J. Comparison of real-time PCR and antigen assays for detection of hepatitis E virus in blood donors. J Clin Microbiol 2014;52:2150–6.10.1128/JCM.03578-13Search in Google Scholar PubMed PubMed Central

40. Malcolm P, Dalton H, Hussaini HS, Mathew J. The histology of acute autochthonous hepatitis E virus infection. Histopathology 2007;51:190–4.10.1111/j.1365-2559.2007.02756.xSearch in Google Scholar PubMed

41. Wedemeyer H, Rybczynska J, Pischke S, Krawczynski K. Immunopathogenesis of hepatitis E virus infection. Semin Liver Dis 2013;33:71–8.10.1055/s-0033-1338118Search in Google Scholar PubMed

42. Tanaka T, Takahashi M, Kusano E, Okamoto H. Development and evaluation of an efficient cell-culture system for Hepatitis E virus. J Gen Virol 2007;88(Pt 3):903–11.10.1099/vir.0.82535-0Search in Google Scholar PubMed

43. Tanaka T, Takahashi M, Takahashi H, Ichiyama K, Hoshino Y, Nagashima S, et al. Development and characterization of a genotype 4 hepatitis E virus cell culture system using a HE-JF5/15F strain recovered from a fulminant hepatitis patient. J Clin Microbiol 2009;47:1906–10.10.1128/JCM.00629-09Search in Google Scholar PubMed PubMed Central

44. Kamar N, Izopet J, Tripon S, Bismuth M, Hillaire S, Dumortier J, et al. Ribavirin for chronic hepatitis E virus infection in transplant recipients. N Engl J Med 2014;370:1111–20.10.1056/NEJMoa1215246Search in Google Scholar PubMed

45. Pischke S, Hardtke S, Bode U, Birkner S, Chatzikyrkou C, Kauffmann W, et al. Ribavirin treatment of acute and chronic hepatitis E: a single-centre experience. Liver Int 2013;33:722–6.10.1111/liv.12114Search in Google Scholar PubMed

46. Zhao Q, Zhang J, Wu T, Li SW, Ng MH, Xia NS, et al. Antigenic determinants of hepatitis E virus and vaccine-induced immunogenicity and efficacy. J Gastroenterol 2013;48:159–68.10.1007/s00535-012-0701-1Search in Google Scholar PubMed PubMed Central

47. WHO Strategic Advisory Group of Experts on Immunization (SAGE) by the Hepatitis E Vaccine Working Group. Recommendations of HEV Working Group on the use of hepatitis E vaccine. 2014.Search in Google Scholar

Article note

Original German online version at: http://www.degruyter.com/view/j/labm.2015.39.issue-6/labmed-2015-0046/labmed-2015-0046.xml?format=INT. The German article was translated by Compuscript Ltd. and authorized by the authors.

Received: 2015-5-24
Accepted: 2015-6-1
Published Online: 2015-12-8

©2015 by De Gruyter

This article is distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Articles in the same Issue

  1. The influence of the trace element zinc on the immune system
  2. Lipoprotein(a): when to measure, how to treat?
  3. Diagnostics and importance of hepatitis E virus infections
  4. Hemoglobin variants – pathomechanism, symptoms and diagnosis
  5. In-vitro allergy diagnostics
  6. Diagnostics of myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML)
  7. A systematic approach to billing laboratory services – the legal framework: Supplement and update to the article in J Lab Med 2014; 38(4):179–205
  8. Diagnostic relevance of CSF interleukin-6
  9. Stepwise diagnostic procedure for the analysis of pathological changes of leukocytes
  10. Simple estimation of reference intervals from routine laboratory data
  11. Rational diagnostic work-up of anemia
  12. Quality assurance in the analysis of growth hormone and insulin-like growth factor I in disorders of the somatotropic axis
  13. Stepwise diagnostics of hemoglobinopathies
https://doi.org/10.1515/labmed-2015-0070
Keywords for this article
antibody test; diagnostic methods; hepatitis E virus; RT-PCR; virus detection
Creative Commons
BY-NC-ND 3.0

Articles in the same Issue

  1. The influence of the trace element zinc on the immune system
  2. Lipoprotein(a): when to measure, how to treat?
  3. Diagnostics and importance of hepatitis E virus infections
  4. Hemoglobin variants – pathomechanism, symptoms and diagnosis
  5. In-vitro allergy diagnostics
  6. Diagnostics of myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML)
  7. A systematic approach to billing laboratory services – the legal framework: Supplement and update to the article in J Lab Med 2014; 38(4):179–205
  8. Diagnostic relevance of CSF interleukin-6
  9. Stepwise diagnostic procedure for the analysis of pathological changes of leukocytes
  10. Simple estimation of reference intervals from routine laboratory data
  11. Rational diagnostic work-up of anemia
  12. Quality assurance in the analysis of growth hormone and insulin-like growth factor I in disorders of the somatotropic axis
  13. Stepwise diagnostics of hemoglobinopathies
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 13.9.2025 from https://www.degruyterbrill.com/document/doi/10.1515/labmed-2015-0070/html
Scroll to top button