Acute Hepatitis E Virus infection with coincident reactivation of Epstein-Barr virus infection in an immunosuppressed patient with rheumatoid arthritis: a case report.

BACKGROUND: Hepatitis E virus (HEV) is the most recently discovered of the hepatotropic viruses, and is considered an emerging pathogen in developed countries with the possibility of fulminant hepatitis in immunocompromised patients. Especially in the latter elevated transaminases should be taken as a clue to consider HEV infection, as it can be treated by discontinuation of immunosuppression and/or ribavirin therapy. To our best knowledge, this is a unique case of autochthonous HEV infection with coincident reactivation of Epstein-Barr virus (EBV) infection in an immunosuppressed patient with rheumatoid arthritis (RA). CASE PRESENTATION: A 68-year-old Swiss woman with RA developed hepatitis initially diagnosed as methotrexate-induced liver injury, but later diagnosed as autochthonous HEV infection accompanied by reactivation of her latent EBV infection. She showed confounding serological results pointing to three hepatotropic viruses (HEV, Hepatitis B virus (HBV) and EBV) that could be resolved by detection of HEV and EBV viraemia. The patient recovered by temporary discontinuation of immunosuppressive therapy. CONCLUSIONS: In immunosuppressed patients with RA and signs of liver injury, HEV infection should be considered, as infection can be treated by discontinuation of immunosuppression. Although anti-HEV-IgM antibody assays can be used as first line virological tools, nucleic acid amplification tests (NAAT) for detection of HEV RNA are recommended--as in our case--if confounding serological results from other hepatotropic viruses are obtained. After discontinuation of immunosuppressive therapy, our patient recovered from both HEV infection and reactivation of latent EBV infection without sequelae

Diagnostic et traitement de la carence en fer sans anémie [Diagnosis and treatment of iron deficiency without anaemia]

Iron deficiency (ID) without anaemia frequently remains undiagnosed when symptoms are attributed to ID with anaemia. Serum ferritin is the primary diagnostic parameter, whereas <10 microg/l represent depleted iron stores, 10-30 microg/l can confirm ID without anaemia and 30-50 microg/l might indicate functional ID. In case of increased CRP or ALT, normal/elevated ferritin should be interpreted with caution. IV iron is indicated if oral iron is not effective or tolerated. At ferritin <10 microg/l, a cumulative dose of 1000 mg iron and at ferritin 10-30 microg/l, a cumulative dose of 500 mg is advised. At ferritin 30-50 microg/l a first dose of 200 mg might be considered. Ferritin shall be reassessed not sooner than 2 weeks after the last oral or 8-12 weeks after the last IV iron administration