Neurological Manifestations of HEV Infection: A Rare Phenomenon or an Underrecognized Reality?

Abstract

Hepatitis E virus; Neuralgic amyotrophy; Neurologic manifestations

Virus de la hepatitis E; Amiotrofia neurálgica; Manifestaciones neurológicas

Virus de l'hepatitis E; Amiotròfia neuràlgica; Manifestacions neurològiques

Aim: This study aimed to describe neurological manifestations secondary to hepatitis E virus (HEV) through the description of two clinical cases. Methods: Two different cases of neuralgic amyotrophy and meningoradiculitis are evaluated in the emergency department of a tertiary referral hospital in 2024. Results: Case 1: A 43-year-old male presented to the emergency department with proximal weakness and pain in the right upper extremity associated with acute onset of orthopnea. Laboratory tests revealed elevated AST/ALT levels (184/1164 IU/L) and positive HEV IgM and IgG, with detectable serum HEV viral load. Cerebrospinal fluid (CSF) was negative for HEV RNA. A significant decrease in forced vital capacity was observed on transition from the upright to the supine position. Electromyography showed severe bilateral phrenic nerve involvement. The diagnosis of neuralgic amyotrophy with diaphragmatic paralysis secondary to HEV was made. The patient was treated with intravenous immunoglobulins and noninvasive ventilation with partial improvement. Case 2: A 37-year-old male presented to the emergency department with paresthesias and weakness, initially affecting the distal upper and lower extremities and progressing proximally. Laboratory tests showed elevated AST/ALT levels (238/626 IU/L), positive HEV IgM and IgG, and a detectable HEV viral load in serum. HEV RNA was also detected in the CSF. Neurophysiological findings were normal. The patient was diagnosed with acute meningoradiculitis secondary to HEV. Treatment with intravenous immunoglobulins led to complete resolution of symptoms. Conclusions: In cases of acute neurological symptoms and liver dysfunction, HEV should be considered as a potential causative agent.