Volume 25, Number 6—June 2019
Research Letter
Hepatitis Rebound after Infection with Yellow Fever Virus
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Blandine Denis
, David Chirio, Diane Ponscarme, Ségolène Brichler, Nathalie Colin de Verdière, François Simon, and Jean-Michel Molina
, David Chirio, Diane Ponscarme, Ségolène Brichler, Nathalie Colin de Verdière, François Simon, and Jean-Michel MolinaAbstract
In 2018, yellow fever with hepatitis was diagnosed for 2 unvaccinated travelers returning to France from Brazil. Hepatitis persisted for >6 months; liver enzyme levels again increased 2 months after disease onset with no detection of yellow fever virus RNA or other pathogens. Persistent hepatitis with hepatic cytolysis rebound probably resulted from immune response.
Although most cases of yellow fever are asymptomatic, some lead to severe liver disease, caused by liver cell cytolysis. In February 2018, yellow fever with hepatitis was diagnosed for 2 patients returning to France after travel to Brazil (Rio de Janeiro coastal area, including the island of Ilha Grande). Both were previously healthy, HIV-negative men, 38 (patient A) and 28 (patient B) years of age; neither had been vaccinated against yellow fever. Their first signs and symptoms occurred 7 (patient B) and 8 (patient A) days after arrival in Brazil, and they sought care in France on day 7 of symptom onset.
Each patient had fever, jaundice, asthenia, thrombocytopenia (57,000 [patient A] and 61,000 [patient B] platelets/mm3; reference range >150,000 platelets/mm3), and hepatitis (alanine aminotransferase [ALT] >5,000 IU/L and aspartate aminotransferase [AST] >3,400 IU/L; reference range <40 IU/L). One patient also had acute renal failure (serum creatinine 170 µmol/L). For both patients, malaria blood smear was negative, IgM against yellow fever virus was detected on 3 evaluations by IgM capture ELISA, and seroconversion was confirmed by detection of yellow fever virus IgG by indirect ELISA at the National Reference Center for Arboviruses (HIA Laveran, Marseille, France). Results of testing for other viruses (dengue [4 serotypes]; chikungunya; Zika; hepatitis A, B, C, E; cytomegalovirus; and Epstein-Barr) were negative. The patients showed no sign of bleeding and were discharged 2 (patient B) and 3 (patient A) days after admission, after thrombocytopenia and liver enzyme elevations had improved.
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