Figure. . Clinical and laboratory data for a 60-year-old man with hepatitis E and lymphocytic leukemia, Italy, 2012. Start of ribavirin treatment and virologic response are indicated. A differential diagnosis was obtained by using abdominal ultrasound, which showed an enlarged hypoechogenic liver and thickening of the gallbladder wall (5 mm) with gallstones in the lumen, but a regular biliary tree. An enlarged spleen (bipolar diameter 15.07 cm) and lymph nodes were attributed to chronic lymphocytic leukemia. Test results for the following markers were negative: viral hepatitis A, B, and C; hepatitis B virus DNA (nested PCR; Roche, Switzerland); hepatitis C virus (nested PCR; Roche); cytomegalovirus virus DNA; Epstein-Barr virus; Q fever; agglutination for Leptospira spp. (Galton's test); enteric fever; Borrelia spp.; Bartonella spp.; autoantibodies (anti-nuclear, anti–liver kidney microsomal, anti-mitochondrial); blood and feces cultures; and ova and parasites in feces. HEV, hepatitis E virus; NA, not available; AST, aspartate aminotransferase; ALT, alanine aminotransferase. Reference ranges were 8–48 IU/L for AST, 7–55 IU/L for ALT, and 0.1–1.0 mg/dL for total bilirubin.