Case Report: Henoch–Schönlein-like purpura as an unusual presentation of acute hepatitis E virus infection

Introduction Hepatitis E virus (HEV) infection is increasingly recognized as a cause of extrahepatic manifestations; however, cutaneous purpuric manifestations are exceptionally rare, with only one previous case of Henoch–Schönlein purpura (HSP) reported in association with acute HEV infection. Methods This study describes the case of a 91-year-old man admitted with palpable purpura of the lower limbs, associated with jaundice, hypertransaminasemia, and cholestatic abnormalities. Molecular and serological assays were performed. Results Serological testing showed anti-HEV IgM and IgG positivity, and HEV RNA was detected in plasma at a viral load of 15,002 IU/mL. The patient reported consumption of wild-boar meat in the month preceding symptom onset. The purpura resolved spontaneously approximately 10 days after onset, and liver parameters progressively improved, with HEV RNA becoming undetectable at follow-up. Phylogenetic analysis of the patient-derived sequence identified the strain as HEV genotype 3f, belonging to the 3f2 subcluster. The patient-derived sequence showed similarity with European HEV-3f/3f2 human strains and with swine and wild boar strains, supporting a likely zoonotic food-borne origin. Plasma interleukin-6 (IL-6) was elevated at admission during the purpuric manifestation. Discussion To our knowledge, this is the first Italian report of an HSP-like purpura temporally associated with acute HEV genotype 3f infection. This case highlights that acute HEV infection may be considered in the differential diagnosis of patients presenting with palpable purpura, while emphasizing the exceptional rarity of this manifestation.