Atypical presentation of hepatitis E with extremely elevated bilirubin levels: a case report.

Introduction and importance: Hepatitis E virus (HEV) infection is usually self-limiting, with mild to moderate liver enzyme and bilirubin elevations. However, extreme hyperbilirubinemia is uncommon and may resemble more severe hepatic pathologies. This case highlights an atypical HEV presentation with alarmingly high bilirubin levels in a healthy adult. Case presentation: A 34-year-old male textile worker with no prior liver disease presented with a 5-day history of vomiting, jaundice, and lethargy. Initial laboratory results showed total bilirubin of 22.8 mg/dL (direct: 16.1 mg/dL), alanine transaminase (ALT) of 2590 U/L, and lactate dehydrogenase (LDH) of 2330 U/L. Serology was reactive for HEV IgM (5.53 units), while other viral markers were negative. His bilirubin peaked at 60.1 mg/dL on day 4 of admission. He received supportive treatment and gradually improved. At 3  weeks post-discharge, his bilirubin had decreased to 5.4 mg/dL, and on follow-up, liver tests normalized and he was asymptomatic. Clinical discussion: This case illustrates an unusual but self-limiting course of HEV with marked hyperbilirubinemia. Early diagnosis is essential to distinguish it from more severe hepatic conditions, including acute drug-induced liver injury, autoimmune hepatitis flare, ischemic hepatitis, mushroom poisoning, and sepsis-associated cholestasis. Clear, compassionate communication is critical to reduce patient anxiety in the face of alarming lab values. Conclusion: Clinicians should consider HEV in patients presenting with acute hepatitis and extreme hyperbilirubinemia. Prompt diagnosis and patient reassurance are key to effective management.