Abstract Hepatitis E virus is the etiological agent for Hepatitis E infection, which is congruent to Hepatitis A infection. The clinical spectrum of the disease range from asymptomatic self-limiting disease which requires no treatment to life threatening fulminant liver disease in pregnancy, G6PD deficient and post-liver transplant patients, which necessitate urgent treatment. Similarly we are reporting a case of a 28 year old male with no previous known comorbids, who presented in emergency department with low grade fever, yellow discolouration of eyes and upper abdominal pain for last 5-6 days. We affirmed the diagnosis of acute viral hepatitis E with G6PD deficiency. This case had a different prospect of HEV infection and its coexistence with G6PD deficiency, which lead to investigations, management and avoidance of complications of the disease. Keywords: Glucose-6-phosphate dehydrogenase, G6PD, Hepatitis E, Haemolysis. Introduction According to World Health Organization (WHO), every year around 20 million people get infected with hepatitis E virus. 1 Of these 3.3 million people have the disease. 1 Hepatitis E infection in 2015 resulted in around 44000 deaths worldwide. 1,2 The highest prevalence of Hepatitis E is in East Asia and South Asia due to inadequate sanitation. 3-5 It is a mild and self-limiting disease, which requires conservative management with no aggressive mode of treatment. 6,7 Glucose - 6 - phosphate dehydrogenase (G6PD) deficiency is one of the most common type of enzyme deficiencies. It is estimated to affect millions of people worldwide. 6 G6PD deficiency is an X-linked recessive hereditary disorder characterized by abnormally low levels of glucose-6-phosphate dehydrogenase. 6,8 The coexistence of Hepatitis E infection in G6PD patients can result in severe haemolysis, renal failure, anaemia, jaundice and other complications such as fulminant hepatitis and acute liver failure. It may consequence in morbidity and mortality, if critical attention to the patient is not provided immediately. 4,6,9 Case Report On 21st of May 2016, a 28-year-old male, bank executive by profession with no known comorbids, presented in emergency department of Liaquat National Hospital, Karachi with complaints of low grade fever, dark coloured urine, yellow discoloration of eyes and right sided upper abdominal pain for last 5-6 days. On general physical examination the patient was lethargic, dehydrated, jaundiced and pale with a blood pressure of 130/60mmHg, heart rate 112/min, respiratory rate 17/min and temperature of 100°F. On abdominal examination there was tenderness in right hypochondrium and epigastric region. Haematology revealed haemoglobin 3.5gm/dl, WBC 61000/cmm (neutrophils 83%, lymphocyte 15%, eosinophil 2%). Platelets 252,000ml. Biochemistry panel revealed total serum bilirubin of 51 mg/dl with a direct bilirubin of 38.7 mg/dl and indirect bilirubin was 12.9 mg/dl. The alanine aminotransferase (ALT) was 1939 U/L, serum aspartate aminotransferase (AST) was 1217U/L and alkaline phosphatase was 156 U/L. At the time of admission, serum creatinine was 2.22 mg/dl. On 3rd day of admission it escalated upto 8.9 mg/dl and urea was 152 mg/dl. The pro-thrombin time was 11.8sec, and indirect and direct Coombs test was negative. Lactate dehydrogenase was 1482 U/L. On peripheral blood smear numerous blister cells were seen (Figure). Malaria Parasite Test was negative. Viral serologies were positive for IgM anti-bodies to hepatitis E virus (HEV). With all above examination and extensive workup the diagnosis of acute viral hepatitis E infection with G6PD deficiency was determined. The patient was managed in High Dependency Unit (HDU). All hepatotoxic, oxidant and nephrotoxic drugs were avoided. Over the course of next two weeks in the hospital the patient improved clinically and on the basis of Lab reports (total serum bilirubin declined from 51 mg/dl to 45.4 mg/dl. AST from 1217U/L to 107U/L and ALT from 1939 U/L to 166 U/L. Haemoglobin increased to 9.7 J Pak Med Assoc 1397 CASE REPORT Severe haemolysis and renal failure precipitated by hepatitis E virus in G6PD Deficient patient: A case report Baseer Sultan Ahmad, 1 Adeel Ahmad, 2 Sajjad Jamil, 3 Saiyed Abdullah Abubakar Mohsin Ehsanullah, 4 Abeera Munir 5 1-3 Liaquat National Hospital, Karachi, 4,5 Ziauddin University, Karachi. Correspondence: Baseer Sultan Ahmad. Email: baseersultan@gmail.com