Unmasking the Threat: Acute Hepatitis E Virus Infection in a Liver Transplant Recipient.

Hepatitis E virus (HEV) infection is an increasingly recognized cause of acute and chronic hepatitis in immunosuppressed individuals, including solid organ transplant recipients. Although typically self-limited in immunocompetent hosts, HEV infection in transplant recipients may lead to persistent viremia, accelerated fibrosis, and graft dysfunction. We report the case of a 47-year-old man who underwent deceased donor liver transplantation for decompensated metabolic-associated steatohepatitis cirrhosis. Five months post-transplant, he was found to have rising liver enzymes during routine monitoring. Imaging and two liver biopsies showed no evidence of acute cellular rejection. Subsequent evaluation revealed positive HEV IgM and detectable HEV RNA with a viral load of 5.5 million IU/mL. Reduction of immunosuppression and initiation of ribavirin therapy resulted in rapid biochemical improvement and complete viral clearance. HEV RNA remained undetectable at the end of therapy and during extended follow-up. This case highlights the importance of early consideration of HEV infection in liver transplant recipients with unexplained liver enzyme abnormalities. Prompt diagnosis and guideline-concordant management can prevent progression to chronic infection and preserve graft function.