A subset of patients who undergo solid organ transplantation develop chronic HEV infection as evidenced by the presence of persistently elevated transaminase levels, detectable serum HEV RNA, histologic findings compatible with chronic viral hepatitis and absence of other viral causes.^[29] In one study of solid organ transplant recipients, 5% acquired HEV infection of whom half developed chronic infection.^[30] Chronic infection has also been reported in patients undergoing cancer chemotherapy as well as HIV patients.^[31][32]

The natural history of transplant recipients with chronic infection is incompletely understood but progressive disease with the development of cirrhosis has been reported.^[33] Therapy consists of a reduction in immunosuppression which leads to spontaneous clearance in a third of individuals. In addition interferon-alpha and ribavirin or a combination of both have been reported to clear HEV infection in a majority of patients.^[1]