hepatitis e virus ( hev ) infection is an emerging problem in developed countries , but hev is a rare cause of acute viral hepatitis in south korea . several cases of acute hepatitis e infection have been reported in korea [ 2 - 8 ] . most patients of acute hepatitis e infection are self - limiting and require no treatment . moreover , a small number of patients with acute hev genotype 1 or 3 infection have been treated with antiviral therapy [ 9 - 11 ] . however , reports on the clinical significance of use of steroid in patients with cholestatic hepatitis e are very limited . guillain - barr syndrome ( gbs ) is triggered by a preceding infection including acute hepatitis a , b , and c. occasionally , it has been triggered by hev infection [ 12 - 14 ] . we reported a case of persistent cholestasis caused by an autochthonous hev infection that was resolved with steroid treatment . after 2.5 months , the patients developed weakness of the lower limbs , and were diagnosed with gbs associated with acute hepatitis e. on 20 march 2014 , a 58-years - old korean male was referred to our hospital with severe hepatitis of unknown cause . on 10 march 2014 , he was a heavy alcohol drinker , with a consumption rate of 120 g / day of alcohol for 30 years . three months before hospitalization , he ingested raw deer meat with the intention of improving his stamina . he had ingested about 200 g of raw meat obtained from a wild deer captured on jiri - mountain in the gyeongnam province , south korea . on physical examination , he had jaundice , right upper quadrant tenderness and an enlarged liver , but showed no feature of hepatic encephalopathy . initial laboratory data showed white blood cell count of 6.3610/mm ( polymorphonuclear neutrophils , 60.1% ; lymphocytes , 24.1% ; and eosinophils , 2.2% ) , serum total bilirubin level of 23.59 mg / dl , serum aspartate aminotransferase ( ast ) level of 292 iu / l , and serum alanine aminotransferase ( alt ) level of 525 serologic study was negative for immunoglobulin ( ig ) m anti - hepatitis a virus ( hav ) antibody and positive for igg anti - hav antibody . hepatitis b virus surface antigen and antibody to hepatitis c were absent , and hcv rna was negative . abdominal computed tomography showed findings compatible with chronic liver disease with splenomegaly . on the ninth day of admission , laboratory data showed a peak total bilirubin level of > 35.0 mg / dl and liver biopsy and blood test for igm and igg anti - hev ( dia . pro , milan , italy for igg anti - hev elisa and dsi , milan , italy for igm anti - hev elisa ) were performed . on liver biopsy ( fig . 1 ) , the lymphocyte - dominant inflammatory cells were accumulated in the periportal area . sixteen days after admission , we started 30 mg / day of prednisolone despite the normal prothrombin time because of a steady increase in total bilirubin levels and pruritus . on the fourteen day of admission , commercially available immunoassay for igm anti - hev and igg anti - hev were both positive . the optical density value of igm anti - hev was 0.849 ( cut - off value 0.294 ) and igg anti - hev was 3.356 ( cut - off value : 0.367 ) . at the time of the diagnosis of acute hev , we decided to taper steroid therapy , but the total bilirubin level was elevated ( 17.8 mg / dl to 21.3 mg / dl ) after steroid tapering ( 30 mg / day to 5 mg / day over 10 days ) ( fig . , prednisolone was given at a dosage of 20 mg / day , and the dose of steroid was tapered and discontinued after 5 weeks . two months after admission , laboratory data showed a total bilirubin level of 2.30 mg / dl , ast level of 24 iu / l , and alt level of 26 iu / l ( fig . the muscle weakness progressed rapidly and in 2 days he was bedridden , unable to move against gravity . cerebrospinal fluid ( csf ) analysis showed a normal protein concentration ( 44.6 mg / dl ) without cellular response . intravenous immunoglobulin 30 g / day was administered for 5 days , and resulted in significantly improved neurologic symptom . during the follow - up period , igm anti - hev persisted as positive until 6 months after admission ( value 1.883 ) , but igm anti - hev converted negative on 12 months after admission ( value 0.049 ) . at first , we considered his severe jaundice may be a manifestation of alcoholic hepatitis on underlying alcoholic cirrhosis . the diagnosis of acute hepatitis e infection was delayed because we performed blood tests for igm and igg anti - hev due to persistent jaundice on the ninth day of administration . steroid therapy with prednisolone was started on the sixteenth day , because of pruritus and the possibility of acute - on - chronic liver failure with progressive liver injury . immunosuppressive treatment for acute viral hepatitis seems to be counterproductive , hence prednisolone was tapered to 5 mg / day . since the total bilirubin level was elevated after tapering , we decided to continue prednisolone treatment at 20 mg / day . two months after admission , the patients liver function was almost normalized . an ast / alt ratio < 1 and periportal lymphocyte infiltration in the absence of fatty liver , neutrophil infiltration , and mallory bodies suggest that severe jaundice may be caused by viral - induced cholestasis , not alcoholic hepatitis in our case . to our knowledge , this is the second report on supportive steroid therapy for severe acute hev infection . they showed that steroid treatment might be an option to prevent the progression of liver failure in patients with hev induced acute liver injury . in a recent study , 5% of patients with gbs had an associated acute hev infection in the netherlands . in korea , reported hev data on seroprevalence of igg hev ranges from 17% to 27% . however , there has been no report on acute hev complicated by gbs in korea , and this is the first report of gbs in a hepatitis e patient in korea . therefore , further studies are required to determine the frequency of antecedent hev infection in patients with gbs in other geographical areas including korea . extrahepatic symptoms may develop even after the clearance of hev virus and not only during active hev infection . in our case , the neurologic symptom developed at 2.5 months after acute hev infection . hev rna becomes undetectable in blood about 3 weeks after symptom onset with reported sensitivity of hev igm tests between 72% and 98% and specificities between 78.2% and 95.6% . during the follow - up period , igm anti - hev persisted as positive thrice until 1 october 2014 , but igm anti - hev converted to negative on 12 months after admission . recovery of severe cholestasis might just reflect the natural course of hev infection without steroid treatment . however , figure 2 showed that serum bilirubin level was promptly decreased following treatment of steroid . in addition , it is possible that steroid therapy had some influence on the development of gbs . in conclusion , this case suggested that steroid therapy might be a beneficial option to relieve pruritus related to persistent cholestasis complicated with acute hepatitis e infection . in addition , further investigations is needed to assess the prevalence of hev infection in patients with gbs .