First confirmed case of transfusion-transmitted hepatitis E in Australia

In July 2014, a 6-year-old boy underwent a split liver transplant following liver failure of unknown cause and received 18 blood components peri-operatively. In January 2015, routine monitoring revealed elevated levels of serum liver enzymes (alanine aminotransferase, 289 U/L; reference interval, <30 U/L). Two biopsies showed possible but inconclusive evidence of rejection, and alanine aminotransferase levels continued to rise, reaching 1170 U/L, despite anti-rejection treatment. Hepatitis E virus (HEV) testing was performed on a third biopsy sample and HEV RNA was detected by reverse transcription polymerase chain reaction. Retrospective testing of the patient's blood and liver samples showed that he was HEV RNA negative before transplantation, but HEV RNA positive in post-transplant blood from September 2014. After 3 months of ribavirin therapy, the patient's liver enzyme levels normalised and HEV RNA became undetectable. The patient had not consumed uncooked pork products and had no history of contact with swine, a known zoonotic HEV source, or overseas travel. HEV RNA was not detected in donor liver samples tested retrospectively. In July 2015, the case was referred to the Australian Red Cross Blood Service (Blood Service) for investigation into possible transmission by transfusion. HEV RNA and IgG testing was performed on archived samples from all 18 blood donations manufactured into the transfused components. HEV RNA was detected in one donation manufactured into a transfused fresh frozen plasma component. The donor of this component reported no symptoms but had travelled to the south of France, a known high HEV prevalence area, 1 in the 2 months before donation and had eaten local pork products. The timing of travel was consistent with overseasacquired infection and donation during the infectious period. HEV IgG was detected in a subsequent donation with RNA clearance, demonstrating seroconversion. This, together with molecular characterisation of patient and blood product HEV (see the Appendix at mja.com.au), strongly supported transmission by transfusion.