Contributions
Abstract: P726
Type: Poster Sessions
Abstract Category: Clinical aspects of MS - Comorbidity
Introduction: Hepatitis E virus (HEV) is a common cause of hepatitis worldwide and genotype 3 (HEV3) is endemic in Europe. Transmission occurs via consumption of undercooked pork meat and blood products. Although most HEV infections (>90%) are asymptomatic, acute hepatitis and extrahepatic manifestations (e.g. neuralgic amyotrophy) have been described. Immunocompromised individuals can develop chronic HEV infection with rapid progression to liver cirrhosis. If the incidence of acute or chronic HEV infections and their extrahepatic manifestations is increased in multiple sclerosis (MS) patients under disease modifying treatments (DMT) is not known.
Aims and methods: We describe 3 cases of HEV infection in MS patients under oral DMT.
Results:
1st case: female with relapsing-remitting MS (RRMS) (first symptoms (FS) at age of 20, initial diagnosis (ID) at age of 21) was treated 23 months with glatirameracetat and then switched to fingolimod (FGL) due to disease activity. After 10 months on FGL she developed asymptomatic elevation of liver enzymes (LE) (ALT 180 U/I, AST 71 U/I, GGT 121 U/I) and an acute HEV infection was diagnosed by positive serology. Although HEV-PCR in blood was negative FGL was temporally discontinued and reinitiated after normalization of LE. 2nd case: male RRMS patient (FS at age of 35, ID at the age of 40) was treated with FGL for 12 years without signs of disease activity. He then presented with an acute icteric hepatic syndrome. LE were elevated (ALT 2522 U/I, AST 1410 U/I, GGT 430 U/I) and polymerase chain reaction (PCR) confirmed the diagnosis of an acute HEV infection (viraemia: 1400 GEq/ml). FGL was stopped and restarted after 4 weeks when HEV-PCR became negative.
3rd case: a female RRMS patient (FS at age of 48, ID at age of 52) was treated for 70 months with Interferon-ß 1a i.m. and switched to dimethylfumarate (DMF) due to disease activity. After 2 months on DMF she developed a painful shoulder syndrome with a subtle scapula alata. An acute HEV infection with elevation of LE (ALT 527 U/I, AST 311 U/I, GGT 102 U/l) was detected by positive serology. The painful shoulder syndrome was interpreted as “forme fruste” of HEV-associated neuralgic amyotrophy, which resolved spontaneously within a few months.
Conclusion: HEV infection should be considered in the differential diagnosis of drug-induced liver injury in MS patients on DMTs. A laboratory constellation with ALT>AST>GGT should trigger appropriate serological hepatitis testing.
Disclosure: Martin Diebold: no disclosures
Bettina Fischer-Barnicol: no disclosures
Charidimos Tsagkas: no disclosures
- Jens Kuhle: received speaker fees, research support, travel support, and/or served on advisory boards by ECTRIMS, Swiss MS Society, Swiss National Research Foundation, (320030_160221), University of Basel, Bayer, Biogen, Genzyme, Merck, Novartis, Protagen AG, Roche, Teva.
- Ludwig Kappos´ Institution (University Hospital Basel) received in the last 3 years and used exclusively for research support at the Department: steering committee, advisory board and consultancy fees from Actelion, Alkermes, Almirall, Bayer, Biogen, Celgene/Receptos, df-mp, Excemed, GeNeuro SA, Genzyme, Japan Tobacco, Merck, Minoryx, Mitsubishi Pharma, Novartis, Roche, sanofi-aventis, Santhera, Teva, Vianex and royalties for Neurostatus-UHB products. The Research of the MS Center in Basel has been supported by grants from Bayer, Biogen, Novartis, the Swiss MS Society, the Swiss National Research Foundation, the European Union and Roche Research Foundations.
- Tobias Derfuss received speaker fees, research support, travel support, and/or served on Advisory Boards or Steering Committees of Novartis Pharma, Merck, Biogen, Teva, Bayer-Schering, GeNeuro, Mitsubishi Pharma, MedDay, Roche, and Genzyme; he received research support from Biogen, Novartis, Swiss National Research Foundation, University of Basel, and Swiss MS Society.
- Bernhard Décard received travel support and / or fees for the institution (University Hospital Basel) from advisory boards or speaker fees from Allmirall, Biogen, Genzyme, Roche, Teva, Novartis, that were used exclusively for research support.
Abstract: P726
Type: Poster Sessions
Abstract Category: Clinical aspects of MS - Comorbidity
Introduction: Hepatitis E virus (HEV) is a common cause of hepatitis worldwide and genotype 3 (HEV3) is endemic in Europe. Transmission occurs via consumption of undercooked pork meat and blood products. Although most HEV infections (>90%) are asymptomatic, acute hepatitis and extrahepatic manifestations (e.g. neuralgic amyotrophy) have been described. Immunocompromised individuals can develop chronic HEV infection with rapid progression to liver cirrhosis. If the incidence of acute or chronic HEV infections and their extrahepatic manifestations is increased in multiple sclerosis (MS) patients under disease modifying treatments (DMT) is not known.
Aims and methods: We describe 3 cases of HEV infection in MS patients under oral DMT.
Results:
1st case: female with relapsing-remitting MS (RRMS) (first symptoms (FS) at age of 20, initial diagnosis (ID) at age of 21) was treated 23 months with glatirameracetat and then switched to fingolimod (FGL) due to disease activity. After 10 months on FGL she developed asymptomatic elevation of liver enzymes (LE) (ALT 180 U/I, AST 71 U/I, GGT 121 U/I) and an acute HEV infection was diagnosed by positive serology. Although HEV-PCR in blood was negative FGL was temporally discontinued and reinitiated after normalization of LE. 2nd case: male RRMS patient (FS at age of 35, ID at the age of 40) was treated with FGL for 12 years without signs of disease activity. He then presented with an acute icteric hepatic syndrome. LE were elevated (ALT 2522 U/I, AST 1410 U/I, GGT 430 U/I) and polymerase chain reaction (PCR) confirmed the diagnosis of an acute HEV infection (viraemia: 1400 GEq/ml). FGL was stopped and restarted after 4 weeks when HEV-PCR became negative.
3rd case: a female RRMS patient (FS at age of 48, ID at age of 52) was treated for 70 months with Interferon-ß 1a i.m. and switched to dimethylfumarate (DMF) due to disease activity. After 2 months on DMF she developed a painful shoulder syndrome with a subtle scapula alata. An acute HEV infection with elevation of LE (ALT 527 U/I, AST 311 U/I, GGT 102 U/l) was detected by positive serology. The painful shoulder syndrome was interpreted as “forme fruste” of HEV-associated neuralgic amyotrophy, which resolved spontaneously within a few months.
Conclusion: HEV infection should be considered in the differential diagnosis of drug-induced liver injury in MS patients on DMTs. A laboratory constellation with ALT>AST>GGT should trigger appropriate serological hepatitis testing.
Disclosure: Martin Diebold: no disclosures
Bettina Fischer-Barnicol: no disclosures
Charidimos Tsagkas: no disclosures
- Jens Kuhle: received speaker fees, research support, travel support, and/or served on advisory boards by ECTRIMS, Swiss MS Society, Swiss National Research Foundation, (320030_160221), University of Basel, Bayer, Biogen, Genzyme, Merck, Novartis, Protagen AG, Roche, Teva.
- Ludwig Kappos´ Institution (University Hospital Basel) received in the last 3 years and used exclusively for research support at the Department: steering committee, advisory board and consultancy fees from Actelion, Alkermes, Almirall, Bayer, Biogen, Celgene/Receptos, df-mp, Excemed, GeNeuro SA, Genzyme, Japan Tobacco, Merck, Minoryx, Mitsubishi Pharma, Novartis, Roche, sanofi-aventis, Santhera, Teva, Vianex and royalties for Neurostatus-UHB products. The Research of the MS Center in Basel has been supported by grants from Bayer, Biogen, Novartis, the Swiss MS Society, the Swiss National Research Foundation, the European Union and Roche Research Foundations.
- Tobias Derfuss received speaker fees, research support, travel support, and/or served on Advisory Boards or Steering Committees of Novartis Pharma, Merck, Biogen, Teva, Bayer-Schering, GeNeuro, Mitsubishi Pharma, MedDay, Roche, and Genzyme; he received research support from Biogen, Novartis, Swiss National Research Foundation, University of Basel, and Swiss MS Society.
- Bernhard Décard received travel support and / or fees for the institution (University Hospital Basel) from advisory boards or speaker fees from Allmirall, Biogen, Genzyme, Roche, Teva, Novartis, that were used exclusively for research support.