• View in gallery

    Phylogenetic tree based on nucleotide sequences of a 260-bp region within the ORF2 gene of HEV. 77HU is the case described in this paper, and it is shown in bold. Bootstrap values were determined on 1,000 resamplings of the data sets. The sequence reported in this work was compared with 63 selected sequences from the genotype 3 available in the GenBank database, including strains from human (□) and swine (•) origin.

  • 1

    Mayo MA, 2005. Changes to virus taxonomy. Arch Virol 150 :189–198.

  • 2

    Okamoto H, 2007. Genetic variability and evolution of hepatitis E virus. Virus Res 127 :216–228.

  • 3

    Piper-Jenks N, Horowitz HW, Schwartz E, 2000. Risk of hepatitis E infection to travelers. J Travel Med 4 :194–199.

  • 4

    Buti M, Clemente-Casares P, Jardi R, Formiga-Cruz M, Schaper M, Valdes A, Rodriguez-Frias F, Esteban R, Girones R, 2004. Sporadic cases of acute autochthonous hepatitis E in Spain. J Hepatol 41 :126–131.

    • Search Google Scholar
    • Export Citation
  • 5

    Mateos ML, Molina A, Ta TH, Moreira V, Milicua JM, Bárcena R, 2006. Acute hepatitis E in Madrid: description of 18 cases. Gastroenterol Hepatol 29 :397–400.

    • Search Google Scholar
    • Export Citation
  • 6

    Ijaz S, Arnold E, Banks M, Bendall RP, Cramp ME, Cunningham R, Dalton HR, Harrison TJ, Hill SF, Macfarlane L, Meigh RE, Shafi S, Sheppard MJ, Smithson J, Wilson MP, Teo CG, 2005. Non-travel-associated hepatitis E in England and Wales: demographic, clinical, and molecular epidemiological characteristics. J Infect Dis 7 :1166–1172.

    • Search Google Scholar
    • Export Citation
  • 7

    Perez-Gracia MT, Garcia-Valdivia MS, Galan F, Rodriguez-Iglesias MA, 2004. Detection of hepatitis E virus in patients sera in southern Spain. Acta Virol 48 :197–200.

    • Search Google Scholar
    • Export Citation
  • 8

    Fernández-Barredo S, Galiana C, Garcia A, Vega S, Gómez MT, Perez-Gracia MT, 2006. Detection of hepatitis E virus shedding in feces of pigs at different stages of production using reverse transcription-polymerase chain reaction. J Vet Diag Invest 18 :462–465.

    • Search Google Scholar
    • Export Citation
  • 9

    Jary C, 2005. Hepatitis E and meat carcasses. Br J Gen Pract 55 :557–558.

  • 10

    Yazaki Y, Mizuo H, Takahashi M, Nishizawa T, Sasaki N, Gotanda Y, Okamoto H, 2003. Sporadic acute or fulminant hepatitis E in Hokkaido, Japan, may be food-borne, as suggested by the presence of hepatitis E virus in pig liver as food. J Gen Virol 84 :2351–2357.

    • Search Google Scholar
    • Export Citation
  • 11

    Takahashi K, Kitajima N, Abe N, Mishiro S, 2004. Complete or near complete nucleotide sequences of hepatitis E virus genome recovered from a wild boar, a deer, and four patients who ate the deer. Virology 330 :501–505.

    • Search Google Scholar
    • Export Citation
  • 12

    Tei S, Kitajima N, Takahashi K, Mishiro S, 2003. Zoonotic transmission of hepatitis E virus from deer to human beings. Lancet 362 :371–373.

    • Search Google Scholar
    • Export Citation
  • 13

    Meng XJ, Halbur PG, Shapiro MS, Govindarajan S, Bruna JD, Mushahwar IK, Purcell RH, Emerson SU, 1998. Genetic and experimental evidence for cross-species infection by swine hepatitis E virus. J Virol 72 :9714–9721.

    • Search Google Scholar
    • Export Citation
  • 14

    Fernández-Barredo S, Galiana C, García A, Gómez-Muñoz MT, Vega S, Rodríguez-Iglesias MA, Pérez-Gracia MT, 2007. Prevalence and genetic characterization of Hepatitis E virus in paired samples of feces and serum from naturally infected pigs. Can J Vet Res 71 :236–240.

    • Search Google Scholar
    • Export Citation
  • 15

    Lu L, Li C, Hagedorn CH, 2006. Phylogenetic analysis of global hepatitis E virus sequences: genetic diversity, subtypes and zoonosis. Rev Med Virol 16 :5–36.

    • Search Google Scholar
    • Export Citation
  • 16

    Meng XJ, Purcell RH, Halbur PG, Lehman JR, Webb DM, Tsareva TS, Haynes JS, Thacker BJ, Emerson SU, 1997. A novel virus in swine is closely related to the human hepatitis E virus. Proc Natl Acad Sci USA 18 :9860–9865.

    • Search Google Scholar
    • Export Citation
  • 17

    Herremans M, Vennema H, Bakker J, van der Veer B, Duizer E, Benne CA, Waar K, Hendrixks B, Schneeberger P, Blaauw G, Kooiman M, Koopmans MP, 2007. Swine-like hepatitis E viruses are a cause of unexplained hepatitis in the Netherlands. J Virol Hepatol 14 :140–146.

    • Search Google Scholar
    • Export Citation
  • 18

    Ahn JM, Kang SG, Lee DY, Shin SJ, Yoo HS, 2005. Identification of novel human hepatitis E virus (HEV) isolates and determination of the seroprevalence of HEV in Korea. J Clin Microbiol 7 :3042–3048.

    • Search Google Scholar
    • Export Citation
  • 19

    Meng XJ, Wiseman B, Elvinger F, Guenette DK, Toth TE, Engle RE, Emerson SU, Purcell RH, 2002. Prevalence of antibodies to hepatitis E virus in veterinarians working with swine and in normal blood donors in the United States and other countries. J Clin Microbiol 1 :117–122.

    • Search Google Scholar
    • Export Citation
  • 20

    Ramachandran J, Eapen CE, Kang G, Abraham P, Hubert DD, Kurian G, Hephzibah J, Mukhopadhya A, Chandy GM, 2004. Hepatitis E superinfection produces severe decompensation in patients with chronic liver disease. J Gastroenterol Hepatol 2 :134–138.

    • Search Google Scholar
    • Export Citation
  • 21

    Amon JJ, Drobeniuc J, Bower WA, Magana JC, Escobedo MA, Williams IT, Bell BP, Armstrong GL, 2006. Locally acquired hepatitis E virus infection, El Paso, Texas. J Med Virol 78 :741–746.

    • Search Google Scholar
    • Export Citation
  • 22

    Dalton HR, Hazeldine S, Banks M, Ijaz S, Bendall R, 2007. Locally acquired hepatitis E in chronic liver disease. Lancet 369 :1260.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 

 

Autochthonous Hepatitis E Infection in a Slaughterhouse Worker

View More View Less
  • 1 Departamento de Atención Sanitaria, Salud Pública y Sanidad Animal, Facultad de Ciencias Experimentales y de la Salud, Universidad CEU Cardenal Herrera, Moncada, Valencia, Spain; Servicio Microbiología, Hospital Ramón y Cajal, Madrid, Spain; Servicio de Gastroenterología, Hospital Ramón y Cajal, Madrid, Spain

We report the first hepatitis E infection case detected in a slaughterhouse worker. The identified strain belonged to genotype 3, subtype 3f. Partial sequence analysis of the strain isolated from his serum showed a percentage of nucleotide homology ranging from 83.4% up to 97.3% compared with European human and swine strains, respectively. These findings point strongly to hepatitis E virus as a vocationally acquired illness by means of the manipulation of infected organs from pigs.

INTRODUCTION

Hepatitis E virus (HEV) is a positive-sense, single-stranded RNA virus without an envelope. This virus is classified in the family Hepeviridae, genus Hepevirus, as the sole member.1 Based on the extensive genomic variability among HEV isolates, HEV sequences have been classified into four genotypes: genotype 1 is comprised of epidemic strains found in Asian and African countries; genotype 2 has been described in Mexico and several African countries; genotype 3 is widely distributed and has been isolated from sporadic cases of acute hepatitis E (HE) and in domestic pigs throughout the world, except in Africa. Genotype 4 is made up of human and swine strains found in Asia.2

HE has been traditionally thought to be enterically transmitted. This epidemiologic pattern has been recorded in developing countries where epidemic outbreaks linked to contaminated drinking water have been reported. However, the epidemiology of HE in industrialized countries may be changing. When it was first reported in developed countries, it was related to travel to endemic areas.3 The rise in acute autochthonous cases in developed regions with no history of traveling to endemic regions4,5 has led HE to be thought as an infection linked to an animal reservoir.6

The origin of sporadic forms in industrialized countries might be caused mainly by the infection by swine HEV.7 The high percentage of nucleotide homology between human and swine strains from the same area supports this assumption. In the same way, the low number of HE cases reported in industrialized countries might be because of the fact that swine HEV strains would be less efficient for infecting humans because they are not as well adapted to humans as the epidemic strains.

This paper describes the infection by HEV of a slaughterhouse worker with a previous history of chronic hepatopathy and the genetic characterization of the strain isolated.

MATERIALS AND METHODS

A 62-year-old male, type 2 diabetic, slaughterhouse worker was admitted to Ramon y Cajal Hospital (Madrid, Spain) with severe jaundice and dark urine of 3-day evolution. In the anamnesis, he reported asthenia, hypopexy, and general weakness during the days previous to the onset of the symptoms. Alcohol consumption was 7 L of beer and 1.5 L of cognac weekly during the last years. On physical examination, the patient was deeply jaundiced and showed a marked right upper and lower back quadrant tenderness. Abdominal computed tomography (CT) scanning was indicative of chronic hepatopathy. Biochemical parameters on admission were as follows: aspartate aminotransferase, 4,320 U/L (reference value < 19 U/L); alanine aminotransferase, 5,727 U/L (reference value < 23 U/L); total bilirubin, 10.4 mg/dL (reference value < 1.3 mg/dL). Serologic markers for infection by hepatitis A (HVA; IgM anti-HAV), B (HBV; HBsAg and anti-HBc), and C (HCV; anti-HCV) viruses (ASXYM; Abbott Laboratories, North Chicago, IL) were negative. Polymerase chain reaction (PCR) for HCV and HBV (Cobas Amplicor; Roche Laboratories, Branchburg, NJ) was also negative. Moreover, Cytomegalovirus, Epstein-Barr virus (ASXYM; Abbott Laboratories and IFA; Oxoid, Hampshire, UK, respectively) and Q fever infections (IFA; Biomerieux, Lyon, France) tested negative.

Finally, immunoglobulin levels of anti-HEV IgM and IgG were detected by a commercial ELISA (Bioelisa HEV IgG and Bioelisa IgM; Biokit, Barcelona, Spain) and were confirmed by Western blot analysis (RecomBlot HEV IgG/IgM; Mikrogen, Martinsried, Germany). In addition, HEV RNA was amplified by reverse transcriptase (RT)-nested PCR8 in two serum samples taken at the moment of admission to the hospital and 3 days later, respectively. Stool samples were not taken.

The patient recovered normal liver function uneventfully within 45 days after his admission to the hospital. No further serum samples were available for the tracking of HEV markers because he was sent to his general practitioner.

RESULTS

The partial sequence of the HEV strain isolated from this patient was obtained and compared with other known human and swine strains of HEV. Phylogenetic analysis of a 260-bp fragment belonging to the ORF2 revealed that this HEV isolate showed a high percentage of homology (87.3–97.3%) with some Spanish swine strains, followed by other Spanish human HEV strains (91.5–96.9%). Compared with other human European strains, the closest homology of this strain was observed with some British HEV strains (83.4–91.5% nucleotide identity). Regarding the comparison to other European swine strains, the highest homology was recorded for Dutch strains (87.3–97.3%), followed by British strains (84.2–86.5%). Most of the nucleotide mutations were found to be silent and did not result in significant differences at the amino acid level. The HEV strain identified in this work showed a 100% amino acid sequence homology compared with other swine and human HEV strains from genotype 3, subtype 3f. A phylogenetic analysis of these sequences is shown in Figure 1.

The HEV sequence identified in this work was deposited in the GenBank database with accession number EF523421.

DISCUSSION

This is the first report of HE infection in a slaughterhouse worker. This patient had no history of traveling to endemic areas, and he had not consumed raw meat or seafood. Moreover, he had not received any blood transfusion or had history of intravenous drug use. The only risk factor he showed seemed to be his occupation. In light of these epidemiologic data, it is reasonable to think that the most probable route of transmission could have been the fecal–oral route after manipulating HEV-infected organs from pigs in the slaughterhouse where he works.

In the literature, there is a case reported in United Kingdom about a butcher suffering from acute HE. This patient spent much of his time butchering pork carcasses imported from the European Community and the Far East. Moreover, another worker from the same butchery was found to have hepatitis antibodies.9

HE infection after consumption of poorly cooked or raw swine liver has been reported.10 Additionally, cases of HE infection by deer and wild boar meat ingestion have been reported.11,12

Recent studies have reported that HE can be a zoonotic illness,13 and the pigs represent the most probable reservoir for human population. In Spain, 25.65% of HEV RNA-positive pigs and 66.66% of HEV RNA-positive pig farms8,14 were found. The high HEV presence detected in this study indicates that this virus is widespread among the swine population in Spain. In this way, it has been observed that anti-HEV IgG seroprevalence in pig handlers and in veterinarians in contact with pigs is elevated in Spain (Galiana and others, unpublished data). All these data support the potential of HEV for spreading among the human population through contact with contaminated organs, crops, or in personnel that handle swine manure and spread this waste on agricultural fields.

The sequence identified in this patient clustered into genotype 3, subtype 3f, following the classification by Lu and others,15 and it was located close to swine Spanish strains (97.3% homology). These data are similar to the data recorded in other industrialized countries between human and swine strains from the same area.6,1618

Phylogenetic analysis showed that the HEV isolate identified in this study clustered in the same genotype with Spanish swine and human HEV and two Dutch strains of swine HEV. The importation of piglets from The Netherlands to Spain seems to be the most probable cause of the close genetic relationship observed between this strain and our patient’s sequence. In Spain, the importation of live piglets is usual, because there is not enough production of them to cover the free vacancies in grower-to-finisher farms. Thus, Spain is the third importer from Europe, and piglets are mainly bought from The Netherlands.

A high seroprevalence in a healthy population without previous history of hepatitis in industrialized countries has been reported.19 These data suggest that HEV infection is subclinical in an undetermined proportion of the population. This case agreed with the observations reported by other authors20,21 who suggest that age and underlying disease may make symptomatic presentation more likely. In the same way, it has been reported that patients who suffer HEV superinfection of chronic hepatopathy normally show a poor prognosis,22 although in this case, the patient recovered successfully.

In conclusion, HEV could constitute an important public health problem, especially for swine workers (veterinarians, butchers, slaughterhouse workers, pig handlers) who are at a higher risk to be infected; therefore, HE should be considered an occupational disease. Our findings suggest that HEV infection in industrialized countries, like Spain, is an emerging disease. HE diagnosis should be considered in any patient who displays clinical symptoms of acute hepatitis and has been in contact with pigs or its organs.

Figure 1.
Figure 1.

Phylogenetic tree based on nucleotide sequences of a 260-bp region within the ORF2 gene of HEV. 77HU is the case described in this paper, and it is shown in bold. Bootstrap values were determined on 1,000 resamplings of the data sets. The sequence reported in this work was compared with 63 selected sequences from the genotype 3 available in the GenBank database, including strains from human (□) and swine (•) origin.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 77, 5; 10.4269/ajtmh.2007.77.893

*

Address correspondence to Maria Teresa Pérez-Gracia, Departamento de Atención Sanitaria, Salud Pública y Sanidad Animal, Facultad de Ciencias Experimentales y de la Salud, Universidad CEU Cardenal Herrera, Avenida Seminario s/n 46113, Moncada, Valencia, Spain. E-mail: teresa@uch.ceu.es

Authors’ addresses: Maria Teresa Pérez Gracia, M.T. Pérez-Gracia, C. Galiana, S. Fernández-Barredo, and A. García, M.T. Gómez, Departamento de Atención Sanitaria, Salud Pública y Sanidad Animal, Facultad de Ciencias Experimentales y de la Salud, Universidad CEU Cardenal Herrera, Avenida Seminario s/n 46113, Moncada, Valencia, Spain. M.L. Mateos, Servicio de Microbiología, Hospital Ramón y Cajal, Ctra de Colmenar Km 9.1, Madrid 28034, Spain. V. Moreira, Servicio de Gastroenterología, Hospital Ramón y Cajal, Ctra de Colmenar Km 9.1, Madrid 28034, Spain.

Financial support: This work was supported by a grant from CEU Cardenal Herrera University (PRUCH 06/21).

REFERENCES

  • 1

    Mayo MA, 2005. Changes to virus taxonomy. Arch Virol 150 :189–198.

  • 2

    Okamoto H, 2007. Genetic variability and evolution of hepatitis E virus. Virus Res 127 :216–228.

  • 3

    Piper-Jenks N, Horowitz HW, Schwartz E, 2000. Risk of hepatitis E infection to travelers. J Travel Med 4 :194–199.

  • 4

    Buti M, Clemente-Casares P, Jardi R, Formiga-Cruz M, Schaper M, Valdes A, Rodriguez-Frias F, Esteban R, Girones R, 2004. Sporadic cases of acute autochthonous hepatitis E in Spain. J Hepatol 41 :126–131.

    • Search Google Scholar
    • Export Citation
  • 5

    Mateos ML, Molina A, Ta TH, Moreira V, Milicua JM, Bárcena R, 2006. Acute hepatitis E in Madrid: description of 18 cases. Gastroenterol Hepatol 29 :397–400.

    • Search Google Scholar
    • Export Citation
  • 6

    Ijaz S, Arnold E, Banks M, Bendall RP, Cramp ME, Cunningham R, Dalton HR, Harrison TJ, Hill SF, Macfarlane L, Meigh RE, Shafi S, Sheppard MJ, Smithson J, Wilson MP, Teo CG, 2005. Non-travel-associated hepatitis E in England and Wales: demographic, clinical, and molecular epidemiological characteristics. J Infect Dis 7 :1166–1172.

    • Search Google Scholar
    • Export Citation
  • 7

    Perez-Gracia MT, Garcia-Valdivia MS, Galan F, Rodriguez-Iglesias MA, 2004. Detection of hepatitis E virus in patients sera in southern Spain. Acta Virol 48 :197–200.

    • Search Google Scholar
    • Export Citation
  • 8

    Fernández-Barredo S, Galiana C, Garcia A, Vega S, Gómez MT, Perez-Gracia MT, 2006. Detection of hepatitis E virus shedding in feces of pigs at different stages of production using reverse transcription-polymerase chain reaction. J Vet Diag Invest 18 :462–465.

    • Search Google Scholar
    • Export Citation
  • 9

    Jary C, 2005. Hepatitis E and meat carcasses. Br J Gen Pract 55 :557–558.

  • 10

    Yazaki Y, Mizuo H, Takahashi M, Nishizawa T, Sasaki N, Gotanda Y, Okamoto H, 2003. Sporadic acute or fulminant hepatitis E in Hokkaido, Japan, may be food-borne, as suggested by the presence of hepatitis E virus in pig liver as food. J Gen Virol 84 :2351–2357.

    • Search Google Scholar
    • Export Citation
  • 11

    Takahashi K, Kitajima N, Abe N, Mishiro S, 2004. Complete or near complete nucleotide sequences of hepatitis E virus genome recovered from a wild boar, a deer, and four patients who ate the deer. Virology 330 :501–505.

    • Search Google Scholar
    • Export Citation
  • 12

    Tei S, Kitajima N, Takahashi K, Mishiro S, 2003. Zoonotic transmission of hepatitis E virus from deer to human beings. Lancet 362 :371–373.

    • Search Google Scholar
    • Export Citation
  • 13

    Meng XJ, Halbur PG, Shapiro MS, Govindarajan S, Bruna JD, Mushahwar IK, Purcell RH, Emerson SU, 1998. Genetic and experimental evidence for cross-species infection by swine hepatitis E virus. J Virol 72 :9714–9721.

    • Search Google Scholar
    • Export Citation
  • 14

    Fernández-Barredo S, Galiana C, García A, Gómez-Muñoz MT, Vega S, Rodríguez-Iglesias MA, Pérez-Gracia MT, 2007. Prevalence and genetic characterization of Hepatitis E virus in paired samples of feces and serum from naturally infected pigs. Can J Vet Res 71 :236–240.

    • Search Google Scholar
    • Export Citation
  • 15

    Lu L, Li C, Hagedorn CH, 2006. Phylogenetic analysis of global hepatitis E virus sequences: genetic diversity, subtypes and zoonosis. Rev Med Virol 16 :5–36.

    • Search Google Scholar
    • Export Citation
  • 16

    Meng XJ, Purcell RH, Halbur PG, Lehman JR, Webb DM, Tsareva TS, Haynes JS, Thacker BJ, Emerson SU, 1997. A novel virus in swine is closely related to the human hepatitis E virus. Proc Natl Acad Sci USA 18 :9860–9865.

    • Search Google Scholar
    • Export Citation
  • 17

    Herremans M, Vennema H, Bakker J, van der Veer B, Duizer E, Benne CA, Waar K, Hendrixks B, Schneeberger P, Blaauw G, Kooiman M, Koopmans MP, 2007. Swine-like hepatitis E viruses are a cause of unexplained hepatitis in the Netherlands. J Virol Hepatol 14 :140–146.

    • Search Google Scholar
    • Export Citation
  • 18

    Ahn JM, Kang SG, Lee DY, Shin SJ, Yoo HS, 2005. Identification of novel human hepatitis E virus (HEV) isolates and determination of the seroprevalence of HEV in Korea. J Clin Microbiol 7 :3042–3048.

    • Search Google Scholar
    • Export Citation
  • 19

    Meng XJ, Wiseman B, Elvinger F, Guenette DK, Toth TE, Engle RE, Emerson SU, Purcell RH, 2002. Prevalence of antibodies to hepatitis E virus in veterinarians working with swine and in normal blood donors in the United States and other countries. J Clin Microbiol 1 :117–122.

    • Search Google Scholar
    • Export Citation
  • 20

    Ramachandran J, Eapen CE, Kang G, Abraham P, Hubert DD, Kurian G, Hephzibah J, Mukhopadhya A, Chandy GM, 2004. Hepatitis E superinfection produces severe decompensation in patients with chronic liver disease. J Gastroenterol Hepatol 2 :134–138.

    • Search Google Scholar
    • Export Citation
  • 21

    Amon JJ, Drobeniuc J, Bower WA, Magana JC, Escobedo MA, Williams IT, Bell BP, Armstrong GL, 2006. Locally acquired hepatitis E virus infection, El Paso, Texas. J Med Virol 78 :741–746.

    • Search Google Scholar
    • Export Citation
  • 22

    Dalton HR, Hazeldine S, Banks M, Ijaz S, Bendall R, 2007. Locally acquired hepatitis E in chronic liver disease. Lancet 369 :1260.

Save