Snapshot A 28-year-old woman is brought by her husband to the emergency department with nausea, malaise, pruritus, and severe abdominal pain. Her symptoms began yesterday and have since worsened. Her husband reports that she appears "yellow" and has been mildly confused. She is currently pregnant at 29 weeks gestation and recently emigrated from India to the United States. Physical examination demonstrates a jaundiced woman with scleral icterus. She is oriented to person but not to place or time. There is tenderness to palpation in the right upper quadrant of the abdomen with hepatomegaly. Laboratory testing is significant for elevated alanine and aspartate aminotransferases and anti-HEV IgM antibodies. Introduction Classification an Orthohepevirus from the family Hepeviridae a nonenveloped, single-stranded, positive-sense RNA virus that has an icosahedral capsid Epidemiology incidence causes clinically apparent hepatitis in India Asia Africa Central America Transmission fecal-oral waterborne secondary to fecal contamination Pathogenesis not clear but believed to be immune-mediated Prognosis usually self-limited in acute infection can be fatal in pregnant women the highest risk in the 3rd trimester, leading to fulminant hepatic failure Presentation Symptoms nausea and vomiting abdominal pain anorexia Physical exam scleral icterus jaundice hepatomegaly Studies Serologic testing presence of anti-HEV antibodies elevate aminotransferases Differential Hepatitis A infection differentiating factor presence of anti-hepatitis A antibodies in serological testing Hepatitis B infection differentiating factor presence of anti-hepatitis B antibodies in serological testing Hepatitis C infection differentiating factor presence of anti-hepatitis C antibodies in serological testing Treatment Conservative supportive management indication mainstay of treatment Complications Fulminant hepatic failure in pregnancy