Measles Reemergence in Ceará, Northeast Brazil, 15 Years after Elimination

Technical Appendix Figure, panel A). Porcine liver has been implicated as a possible HEV transmission vehicle in that region (6); although we do not know whether the patient ate food that carried HEV, the possibility underscores the importance of avoiding eating inadequately cooked animal-derived food products during international travel (2). Chronic hepatitis with accelerated cirrhosis has been reported in solid-organ transplant recipients infected with HEV genotype 3, but not with genotype 4 (7). Serial liver biopsy specimens from the patient showed persistent and worsening hepatitis and rapid onset of fibrosis that intensified (online Technical Appendix Figure, panel B). Testing for HEV infection is recommended during initial assessments of posttransplant hepatic dysfunction because histologic appearances in liver biopsy specimens may not clearly distinguish between graft rejection and acute viral hepatitis (Figure, panels A, B). Early diagnosis of hepatitis E should lead to prompt administration of antiviral therapy and appropriate adjustments to the immunosuppressant drug regimen, particularly because some drugs can exert opposing effects on HEV replication (8).