Correspondence: S. Festa, School of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy. Tel:  39 06 33775691. Fax:  39 06 33775526. E-mail: festa.stefano@gmail.com (Received 22 April 2014; accepted 19 May 2014) Scandinavian Journal of Infectious Diseases, 2014; Early Online: 1–5 ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.928417 CASE REPORT Acute fulminant hepatitis E virus genotype 3e infection: Description of the first case in Europe STEFANO FESTA 1 , ANNA ROSA GARBUGLIA 2 , FLAVIA BACCINI 1 , FRANCESCO PANZUTO 1 , MARIA ROSARIA CAPOBIANCHI 2 , IOLANDA SANTINO 3 , FLAMINIA PURCHIARONI 1 , GIANLUIGI ORGERA 4 , GIANFRANCO DELLE FAVE 1 & MASSIMO MARIGNANI 1 From the 1 Digestive and Liver Disease Unit, School of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea Hospital, 2 Laboratory of Virology, National Institute for Infectious Diseases “Lazzaro Spallanzani, 3 Department of Clinical and Molecular Medicine, School of Medicine and Psychology, Sapienza University of Rome, and 4 Radiology Unit, School of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea Hospital, Rome, Italy Abstract Hepatitis E virus (HEV) is the most important causative agent of acute hepatitis in developing countries. The disease is usually characterized by a self-limiting, benign course. However, when particular conditions coexist (pregnancy, old age, pre-existing liver disease) it may run an unfavourable course. To date, 4 HEV genotypes have been described. Historically, in the Western world, HEV infection was considered a travel-related disease, however in the last 2 decades a great number of non-travel-related autochthonous cases have been described, more often related to genotype 3 or 4 and in the context of zoonosis. We report the case of an elderly Italian man with an acute fulminant HEV infection genotype 3e that developed in the context of pre-existing liver disease; this is the first case of an unfavourable outcome associated with subgenotype 3e. The potential pathogenicity of this subgenotype together with the influence of host-related risk factors are discussed. Keywords: Hepatitis E virus, fulminant, phylogenetic tree, genotype, epidemiology, ribavirin Introduction The hepatitis E virus (HEV) is a single-stranded RNA virus of the Hepeviridae family. Four major genotypes have been described to date [1]. In hyper- endemic regions, HEV is the most common causative agent of acute viral hepatitis, which may evolve into fulminant hepatitis, especially in pregnant women or when a chronic liver disease coexists [2]. Genotypes 1 and 2, only found in humans, are mainly transmit- ted through the faecal–oral route and are responsible for acute, but usually self-limiting and benign hepa- titis in endemic countries of tropical and subtropical regions [1]. Genotypes 3 and 4 can also infect animals, especially swine, and deer, which serve as reservoirs sustaining the circulation of the virus in human populations [1]. The consumption of undercooked contaminated animal meat and direct contact with infected animals are the main potential routes of transmission, and blood-borne transmission may also occur [1]. HEV genotype 3 has been considered responsible for an increasing number of non-travel- related autochthonous cases in developed countries, especially affecting middle aged/elderly men [3–8]. Differently from the above-mentioned reports, we describe the clinical picture of an acute fulminant HEV genotype 3e infection complicating chronic liver disease in an elderly Italian man living in central Italy. To the best of our knowledge this is the first report to describe a fulminant HEV genotype 3 infection related to subgenotype e. The manage- ment of this case and the presence of host-related Scand J Infect Dis Downloaded from informahealthcare.com by Ins Naz Malattie Infett on 09/10/14 For personal use only.