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Gutierrez Sanchez LH, Ibrahim SH. Severe Acute Hepatitis of Unknown Etiology in Children: New Virus or Immune Dysregulation. Gastroenterology 2024:S0016-5085(24)00481-5. [PMID: 38663818 DOI: 10.1053/j.gastro.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 06/02/2024]
Affiliation(s)
- Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Samar H Ibrahim
- Division of Gastroenterology and Hepatology, Division of Pediatric Gastroenterology, Mayo Clinic, Rochester, Minnesota
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Cohen A, Alvarez F. Immunosuppression in two cases of indeterminate hepatitis. CANADIAN LIVER JOURNAL 2024; 7:64-69. [PMID: 38505788 PMCID: PMC10946185 DOI: 10.3138/canlivj-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/16/2023] [Indexed: 03/21/2024]
Abstract
Background Pediatric acute liver failure (PALF) is a potentially lethal and rapidly progressive clinical syndrome, with a large proportion of cases remaining indeterminate despite extensive investigations. Patients and Results In this case report, we describe two male children with indeterminate PALF and a family history of autoimmune disease, both of whom were lymphopenic with necrosis, inflammation, and lymphocytic infiltrates on their liver biopsies. One of these patients subsequently developed hepatitis-associated aplastic anemia. Notably, in addition to receiving standard liver failure care, both patients were successfully treated off-label with anti-thymocyte globulin (ATG), as well as a more prolonged course of cyclosporine and corticosteroids. Conclusions The fact that these medications all suppress T lymphocytes further supports the theory that T-cell activation plays a prominent role in the pathophysiology of indeterminate hepatitis. Further research should examine the short-term and long-term effects of ATG in this population, as well as the necessary duration of treatment with immune-suppressing agents.
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Affiliation(s)
- Alexandra Cohen
- Pediatric Resident, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Fernando Alvarez
- Department of Pediatrics, Université de Montréal, CHU Sainte-Justine, Montréal, Quebec, Canada
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Nastasio S, Mosca A, Alterio T, Sciveres M, Maggiore G. Juvenile Autoimmune Hepatitis: Recent Advances in Diagnosis, Management and Long-Term Outcome. Diagnostics (Basel) 2023; 13:2753. [PMID: 37685291 PMCID: PMC10486972 DOI: 10.3390/diagnostics13172753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023] Open
Abstract
Juvenile autoimmune hepatitis (JAIH) is severe immune-mediated necro-inflammatory disease of the liver with spontaneous progression to cirrhosis and liver failure if left untreated. The diagnosis is based on the combination of clinical, laboratory and histological findings. Prothrombin ratio is a useful prognostic factor to identify patients who will most likely require a liver transplant by adolescence or early adulthood. JAIH treatment consists of immune suppression and should be started promptly at diagnosis to halt inflammatory liver damage and ultimately prevent fibrosis and progression to end-stage liver disease. The risk of relapse is high especially in the setting of poor treatment compliance. Recent evidence however suggests that treatment discontinuation is possible after a prolonged period of normal aminotransferase activity without the need for liver biopsy prior to withdrawal.
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Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Antonella Mosca
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Marco Sciveres
- Pediatric Department and Transplantation, ISMETT, 90133 Palermo, Italy;
| | - Giuseppe Maggiore
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
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Islek A, Tumgor G. Seronegative autoimmune hepatitis in childhood. World J Clin Pediatr 2023; 12:77-85. [PMID: 37342447 PMCID: PMC10278082 DOI: 10.5409/wjcp.v12.i3.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 06/08/2023] Open
Abstract
Comprehensive guidelines on seropositive autoimmune hepatitis have been published for both adults and children, although these guidelines comprise only limited knowledge about seronegative autoimmune hepatitis. Autoimmune hepatitis presents as an acute or chronic progressive disease and poor outcomes are inevitable if left untreated. The absence of autoantibody positivity, hypergammaglobulinemia and lack of comprehensive algorithms makes seronegative autoimmune hepatitis a mysterious disease. In general, seronegative autoimmune hepatitis often presents with acute hepatitis, and its treatment and prognosis similar to seropositive autoimmune hepatitis. The present review focuses on the known characteristics of seronegative autoimmune hepatitis in childhood, and those of which current knowledge is vague.
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Affiliation(s)
- Ali Islek
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
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Chapin CA, Burn TM, Diamond T, Loomes KM, Alonso EM, Behrens EM. Effector memory CD8 T-cells as a novel peripheral blood biomarker for activated T-cell pediatric acute liver failure. PLoS One 2023; 18:e0286394. [PMID: 37267251 PMCID: PMC10237500 DOI: 10.1371/journal.pone.0286394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/12/2023] [Indexed: 06/04/2023] Open
Abstract
A distinct phenotype of pediatric acute liver failure (PALF) has been identified, labeled activated T-cell hepatitis. These patients, previously included within the indeterminate group, have evidence of systemic immune activation and liver biopsy specimens with dense infiltration of CD8+ T-cells. We aimed to evaluate the peripheral blood T-cell phenotype in PALF patients with activated T-cell hepatitis compared to indeterminate cause. PALF patients with unknown etiology age 1-17 years were prospectively enrolled between 2017-2020. Within the unknown group, patients were classified as either activated T-cell hepatitis if they had a liver biopsy with dense or moderate CD8 staining and an elevated soluble interleukin-2 receptor level, or they were classified as indeterminate if they did not meet these criteria. Whole blood was collected for flow cytometry and T-cell phenotyping. Four patients with activated T-cell hepatitis and 4 patients with indeterminate PALF were enrolled. Activated T-cell hepatitis patients had significantly greater percentage of CD8 T-cells that were effector memory (TEM) phenotype compared to indeterminate PALF patients (median 66.8% (IQR 57.4-68.7) vs 19.1% (IQR 13.4-25.2), P = 0.03). In addition, CD8+ TEM cells in activated T-cell hepatitis patients were significantly more likely to be CD103 positive, a marker of tissue resident memory T-cells, compared to indeterminate PALF patients (median 12.4% (IQR 9.5-14.7) vs 4.7% (IQR 4.5-5.3), P = 0.03). We found patients with activated T-cell hepatitis can be identified by the unique pattern of increased percentage of peripheral blood effector memory CD8+ CD103+ T-cells. These findings will guide future studies exploring the T-cell phenotype for these patients and whether they may respond to directed immunosuppressive therapies.
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Affiliation(s)
- Catherine A. Chapin
- Department of Pediatrics, Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois, United States of America
| | - Thomas M. Burn
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Tamir Diamond
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kathleen M. Loomes
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Estella M. Alonso
- Department of Pediatrics, Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois, United States of America
| | - Edward M. Behrens
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Hepatitis-associated Aplastic Anemia. J Pediatr Gastroenterol Nutr 2022; 75:553-555. [PMID: 36070526 DOI: 10.1097/mpg.0000000000003603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hepatitis-associated aplastic anemia (HAAA) accounts for 4% of autoimmune hepatitis in children. An episode of seronegative autoimmune hepatitis is followed a few days or months later by aplastic anemia or full aplasia. This autoimmune disease could be due to a regulation defect in the immune response to a viral trigger, in a genetically predisposed individual. Other causes of hepatitis or aplastic anemia have to be ruled out. Steroids and azathioprine usually control the liver damage but do not prevent the development of aplastic anemia. Aplastic anemia is treated with either hematopoietic stem cell transplantation in patients with a sibling donor or anti-thymocyte globulins and cyclosporine. We propose guidelines to explore and treat this rare disease. We emphasize on the necessary close collaboration between hepatologists and hematologists.
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Thakur W, Anwar N, Samad S, Fatima N, Ahmed R, Tariq F, Ashfaq J, Sharif S, Borhany M. Assessment of Hepatic Profile in Acquired Aplastic Anemia: An Experience From Pakistan. Cureus 2022; 14:e29079. [PMID: 36249635 PMCID: PMC9558489 DOI: 10.7759/cureus.29079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction: Aplastic anemia (AA) is characterized by pancytopenia and hypocellular marrow in the absence of an abnormal infiltrate or increase in reticulin fibrosis. The diagnosis of AA is challenging at times due to decreased cellularity and overlapping morphological features with other bone marrow failure syndromes. Hepatitis-associated aplastic anemia (HAAA) is a rare variant in which patients typically present with jaundice and hepatitis followed by pancytopenia almost within 6 months. Post-hepatitis AA accounts for approximately 1-5% of cases, and invariably such cases are negative for the known hepatitis virus as well. There is limited literature available to understand the correlation of AA with hepatitis with none reported at the national level in our region. As AA is relatively more prevalent in Southeast Asia as compared to the western world and hepatitis is a prevalent disease in our population, the main purpose of this study was to assess the hepatic profile and determine the association of hepatitis in AA at the time of diagnosis. Materials and methods: A cross-sectional study was carried out at the National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, from November 2019 to December 2020 after the informed consent from patients. The study included all treatment-naïve patients of acquired AA with no prior history of taking steroids, immunosuppressive treatment, or chemoradiation therapy. Liver function tests, complete blood count, prothrombin time (PT), and activated partial thromboplastin time were performed, along with viral profiles (HAV, Hep B, Hep C, and HIV). SPSS version 23 (IBM Corp., Armonk, NY) was used for statistical analysis. Mean and standard deviations were computed for quantitative variables while percentages and frequencies were reported for qualitative variables. T-test was used to observe the main difference between groups and a p-value <0.05 was considered to be significant. Results: Out of a total of 351 patients, 29 (8.2%) patients with AA tested positive for viral hepatitis. Hepatitis A was the most prevalent hepatitis (4.0%), followed by hepatitis C (3.7%). The comparison of platelet counts in patients with and without hepatitis was reported to be of statistical significance (p-value < 0.05). A significant statistical difference (p-value < 0.0001) was found in platelet count and PT in patients of AA with and without hepatitis. Conclusion: Overall, this study revealed that <10% of patients of AA had a positive screening for hepatitis A, B, and C and low platelet count, and PT was statistically significant when compared between the patients with and without hepatitis. Hepatitis being prevalent in our part of the world might have an important causal association with AA. Patients with AA should be screened for liver functions and viral hepatitis at the time of diagnosis. In addition to hepatitis A, B, and C and HIV, other causes of hepatitis should also be screened such as parvovirus B19, human herpes virus 16, and adenovirus which are not included in routine diagnostic viral testing panel.
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Kulkarni S, Chapin CA, Alonso EM, Rudnick DA. An Update on Pediatric Acute Liver Failure: Emerging Understanding of the Impact of Immune Dysregulation and Novel Opportunities for Intervention. Clin Liver Dis 2022; 26:461-471. [PMID: 35868685 DOI: 10.1016/j.cld.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pediatric acute liver failure (PALF) is a complex, unpredictable, often rapidly progressive, potentially devastating clinical syndrome that occurs in infants, children, and adolescents without pre-existing liver disease. PALF is characterized by acute onset of hepatocellular injury and liver-based coagulopathy, frequently accompanied by hepatic encephalopathy. Etiologies include drug and toxin exposures, metabolic and genetic disorders, infections, and immune-mediated disease. PALF management primarily involves early contact with and consideration of transfer to a pediatric liver transplant center and intensive supportive multidisciplinary clinical care, with targeted therapies available for a subset of causes. Outcomes include survival with native liver, death, and liver transplantation. Efforts to develop reliable clinical prognostic tools to predict PALF outcomes early in the course of disease have not yet been fulfilled, and the possibility remains that some transplanted PALF patients might have survived without transplantation.
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Affiliation(s)
- Sakil Kulkarni
- Department of Pediatrics, St. Louis Children's Hospital, One Children's Place, St Louis, MO 63110, USA
| | - Catherine A Chapin
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Box 65, 225 E Chicago Avenue, Chicago, IL 60611, USA
| | - Estella M Alonso
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Box 65, 225 E Chicago Avenue, Chicago, IL 60611, USA
| | - David A Rudnick
- Department of Pediatrics, St. Louis Children's Hospital, One Children's Place, St Louis, MO 63110, USA; Department of Developmental Biology, Washington University School of Medicine, 3105 McDonnell Pediatric Research Building, 660 S Euclid Avenue, Campus Box 8208, St Louis, MO 63110, USA.
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Li H, Li X, Chen X, Li N. Successful treatment with HLA-matched peripheral hematopoietic stem cell transplantation for very severe hepatitis-associated aplastic anemia complicated with multidrug-resistant bacterial and fungal infections: A case report. Front Pediatr 2022; 10:828918. [PMID: 36389369 PMCID: PMC9659588 DOI: 10.3389/fped.2022.828918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Hepatitis-associated aplastic anemia (HAAA) is a life-threatening hematologic disorder characterized by bone marrow failure. Allogeneic hematopoietic stem cell transplantation (HSCT) is the first-line treatment for HAAA. Severe infection and complications in patients with very severe aplastic anemia are the challenges to the efficacy of HSCT. We report a rare case of successful transplantation with HLA-matched peripheral hematopoietic stem cells for a 15-year-old girl suffering from HAAA with multidrug-resistant bacterial and fungal infections. Through effectively controlling infection and optimal timing of transplantation by adjusting the conditioning regimen, the allo-HSCT was successfully performed for the patient. Updated data of following-up 26 months after transplantation showed that the patient was still in complete remission with a good quality of life. This case provided a reference for treating severely infected patients with HAAA before HSCT.
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Affiliation(s)
- Hua Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Hematology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Xiaofan Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xianling Chen
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Nainong Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
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Kemme S, Mack CL. Pediatric Autoimmune Liver Diseases: Autoimmune Hepatitis and Primary Sclerosing Cholangitis. Pediatr Clin North Am 2021; 68:1293-1307. [PMID: 34736590 DOI: 10.1016/j.pcl.2021.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In chronic hepatitis, a broad differential diagnosis should be considered to accurately identify the cause(s) of liver injury. Autoimmune liver diseases (autoimmune hepatitis, primary sclerosing cholangitis, overlap syndrome) can occur in the setting of limited symptoms; therefore, a high index of suspicion and appropriate diagnostic workup should be performed. Most children with autoimmune hepatitis achieve sustained remission with medical therapy; however, there are no equivalent therapies for primary sclerosing cholangitis that impact the progression of disease. Research should include biomarker studies to predict histologic remission in autoimmune hepatitis and mechanistic studies to define future treatment targets for primary sclerosing cholangitis.
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Affiliation(s)
- Sarah Kemme
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine and Children's Hospital Colorado, 13123 East 16th Avenue, Mailstop B290, Aurora, CO 80045, USA.
| | - Cara L Mack
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine and Children's Hospital Colorado, 13123 East 16th Avenue, Mailstop B290, Aurora, CO 80045, USA
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