Does co-infection with multiple viruses adversely influence the course and outcome of sporadic acute viral hepatitis in children?

"Quality of life is impaired in children with chronic pancreatitis: A multicenter study"

BACKGROUND AND OBJECTIVES

The impact of chronic pancreatitis (CP) on quality of life (QOL) of children is not well established. Our objective was to evaluate the QOL, identify contributing factors, and determine the prevalence of anxiety and depression in children with CP in India.

METHODS

Children (8-18y old) with CP were prospectively enrolled across three pediatric gastroenterology centres in India. QOL was assessed using the pediatric QOL inventory (PedsQL 4.0) scale, administered to both children and their parents. Anxiety and depression was studied using the Revised Children's Anxiety and Depression Scale (RCADS 25). Contributing factors were identified using binary logistic regression analysis. The data was compared against published QOL data in healthy Indian children.

RESULTS

121 children with CP (boys-57.9 %, age at QOL-14 ± 3.2years) were enrolled. A majority (82.7 %) had pain and advanced disease (Cambridge grade IV- 63.6 %). Children with CP had poorer QOL compared to controls (total score 74.6 ± 16 vs. 87.5 ± 11.1, p < 0.0001). QOL scores were similar across centres. Older children were similar to younger ones, except for a poorer emotional QOL. Taking QOL < -2 standard deviation (SD) of controls, ∼35 % had poor physical (50.9 ± 11.9) and 20 % had poor psychosocial (PS) QOL score (52.1 ± 7.2). On analysis, presence of pain and lower socio-economic status (SES) adversely affected both physical and PS-QOL. Additionally, girls had poorer PS-QOL than boys (Odds ratio 3.1, 95%CI:1.23-7.31). Anxiety and depression were uncommon (2,1.6 %).

CONCLUSIONS

Patients with CP had impaired physical and psycho-social QOL. Presence of pain and lower SES adversely affected QOL. Psychiatric comorbidities were uncommon.

Determinants, profile and outcomes of hepatitis A virus-associated severe acute liver injury in adults

BACKGROUND AND OBJECTIVES

Hepatitis A virus (HAV)-related hepatitis is witnessing an epidemiological transition with increasing trends in adults. While uncomplicated hepatitis remains common, evidence suggests it to be a growing cause for acute liver failure (ALF). In between the two extremes exists severe acute liver injury (s-ALI) which has a propensity to transition to ALF. We aimed at describing the clinical profile of patients with HAV-related s-ALI and identifying potential predictors of progression to ALF.

METHODS

This was a single-center retrospective analysis of adult patients admitted with HAV-related s-ALI between April 2022 and December 2023. Demographic and laboratory parameters were compared between patients with only s-ALI and those with ALF. Predictors of progression from s-ALI to ALF were identified using logistic regression.

RESULTS

Forty-three patients satisfied criteria of s-ALI, of which 33 (76.7%) had only s-ALI, while 10 (23.3%) had ALF. Patients with s-ALI had lesser leukocytosis (6.3 ± 3 vs. 13.2 ± 4.8), less incidence of acute kidney injury (9.1% vs. 40%) and lower model for end-stage liver disease (MELD) (20 [18-24.5] vs. 31.5 [26-42]), arterial lactate (2.1 [1.3-3.1] vs. 6.3 [5.2-8.0]), arterial ammonia (94 [72-118] vs. 299 [188-573]), procalcitonin (0.5 [0.28-1.25] vs. 3.2 [1.2-6.1]) and ferritin (482 [213-1633] vs. 5186 [1341-11,053]) compared to HAV-ALF (p < 0.05 for all). Three patients (9.09%) with s-ALI progressed to ALF of whom one (3%) died. Baseline ammonia levels (unadjusted odds ratio [OR] 1.03 [1.01-1.06]) and leukocyte count (OR 1.00 [1.00-1.01]) tended to be associated with ALF progression, although none was significant after multi-variable adjustment. Ammonia levels had an area under receiver operating curve of 0.816 (0.64-0.93) (p = 0.009) (cut-off of 144 μmol/L). Additional comorbidities did not impact overall outcomes.

CONCLUSION

HAV presents as s-ALI in young adults, with almost one in 10 progressing to ALF. Baseline ammonia may be an important predictor of progression even in s-ALI, but mandates larger well-designed studies.

High Incidence of Acute Liver Failure among Patients in Egypt Coinfected with Hepatitis A and Hepatitis E Viruses

Hepatitis A virus (HAV) and Hepatitis E virus (HEV) are transmitted through the fecal-oral route. HAV outbreaks and one HEV outbreak have been reported in Egypt. However, the impact of HAV-HEV co-infection is not known. In this study, we assessed HEV markers in acute HAV-infected patients (n = 57) enrolled in Assiut University hospitals. We found that 36.8% of HAV-infected patients were also positive for HEV markers (anti-HEV IgM and HEV RNA), while 63.2% of the patients were HAV mono-infected. Demographic and clinical criteria were comparable in both HAV mono-infected patients and HAV-HEV co-infected patients. Although liver enzymes were not significantly different between the two groups, liver transaminases were higher in the co-infected patients. Six patients developed acute liver failure (ALF); five of them were HAV-HEV-co-infected patients. The relative risk of ALF development was 8.5 times higher in HAV-HEV co-infection compared to mono-infection. Three cases of ALF caused by HAV-HEV co-infection were reported in children (below 18 years) and two cases were reported in adults. All patients developed jaundice, coagulopathy, and encephalopathy; all were living in rural communities. In conclusion: HAV-HEV co-infection can be complicated by ALF. The risk of ALF development in HAV-infected patients is higher when coinfection with HEV is present.

Treatment Options for Hepatitis A and E: A Non-Systematic Review

Hepatitis A and hepatitis E are relatively common causes of liver disease. Both viruses are mainly transmitted through the faecal-oral route and, consequently, most outbreaks occur in countries with poor sanitation. An important role of the immune response as the driver of liver injury is also shared by the two pathogens. For both the hepatitis A (HAV) and hepatitis E (HEV) viruses, the clinical manifestations of infection mainly consist of an acute disease with mild liver injury, which results in clinical and laboratory alterations that are self-limiting in most cases. However, severe acute disease or chronic, long-lasting manifestations may occur in vulnerable patients, such as pregnant women, immunocompromised individuals or those with pre-existing liver disease. Specifically, HAV infection rarely results in fulminant hepatitis, prolonged cholestasis, relapsing hepatitis and possibly autoimmune hepatitis triggered by the viral infection. Less common manifestations of HEV include extrahepatic disease, acute liver failure and chronic HEV infection with persistent viraemia. In this paper, we conduct a non-systematic review of the available literature to provide a comprehensive understanding of the state of the art. Treatment mainly consists of supportive measures, while the available evidence for aetiological treatment and additional agents in severe disease is limited in quantity and quality. However, several therapeutic approaches have been attempted: for HAV infection, corticosteroid therapy has shown outcome improvement, and molecules, such as AZD 1480, zinc chloride and heme oxygenase-1, have demonstrated a reduction in viral replication in vitro. As for HEV infection, therapeutic options mainly rely on the use of ribavirin, and some studies utilising pegylated interferon-alpha have shown conflicting results. While a vaccine for HAV is already available and has led to a significant reduction in the prevalence of the disease, several vaccines for HEV are currently being developed, with some already available in China, showing promising results.

Dual Infection of Hepatitis A Virus and Hepatitis E Virus- What Is Known?

Viral hepatitis is an infection of human hepatocytes resulting in liver damage. Dual infection of two hepatotropic viruses affects disease outcomes. The hepatitis A virus (HAV) and hepatitis E virus (HEV) are two enterically transmitted viruses; they are single-stranded RNA viruses and have common modes of transmission. They are transmitted mainly by the fecal-oral route and ingestion of contaminated food, though the HAV has no animal reservoirs. The HAV and HEV cause acute self-limiting disease; however, the HEV, but not HAV, can progress to chronic and extrahepatic infections. The HAV/HEV dual infection was reported among acute hepatitis patients present in developing countries. The impact of the HAV/HEV on the prognosis for acute hepatitis is not completely understood. Studies showed that the HAV/HEV dual infection increased abnormalities in the liver leading to fulminant hepatic failure (FHF) with a higher mortality rate compared to infection with a single virus. On the other hand, other reports showed that the clinical symptoms of the HAV/HEV dual infection were comparable to symptoms associated with the HAV or HEV monoinfection. This review highlights the modes of transmission, the prevalence of the HAV/HEV dual infection in various countries and among several study subjects, the possible outcomes of this dual infection, potential model systems for studying this dual infection, and methods of prevention of this dual infection and its associated complications.

Pediatric acute viral hepatitis with atypical variants: Clinical dilemmas and natural history

Classical acute viral hepatitis (AVH) has an uncomplicated outcome. Acute liver failure has a grave prognosis. Atypical manifestations of AVH are a group of disorders that causes significant morbidity and dilemmas in children. These include prolonged cholestasis, relapsing hepatitis, ascitic form of AVH, late-onset hepatic failure (LOHF), intravascular hemolysis, and provoking an autoimmune trigger leading to autoimmune hepatitis. These entities cause significant liver dysfunction or worsening and are often difficult to differentiate from chronic liver disease (CLD). Ascitic form of AVH, LOHF, decompensated CLD and acute-on-chronic liver failure have significant overlapping features that need to be carefully dissected out. In many cases, only on long-term follow-up, these clinical entities can be separately identified. Intravascular hemolysis is usually caused by associated glucose-6-phosphate dehydrogenase deficiency. Rarely CLD such as Wilson disease and autoimmune hepatitis can also present with hemolysis in the initial presentation, which can mimic AVH with hemolysis. Identifying deviations from typical manifestations aid in avoiding unnecessary investigations, allowing focused therapy and alleviating anxiety.

Atypical manifestations of acute viral hepatitis A in children in Bangladesh: Are these really uncommon?

BACKGROUND/AIM

The aim of this study was to find out the clinical spectrum of acute viral hepatitis A (AVH-A) infection in children, the relationship between atypical manifestations and laboratory findings and the outcome of patients with typical and atypical hepatitis A virus (HAV) manifestations.

METHODS

From January 2018 to September 2019, consecutive children (<18 years of age) with features suggestive of AVH with positive IgM anti-HAV both from inpatient and outpatient services were included in this study. Detailed history, physical findings, and investigations were recorded in the study questionnaire. Patients were followed up weekly until complete recovery. The Statistical Package for the Social Sciences (SPSS) version 22 was used for statistical analysis.

RESULT

The mean age of 200 children who were finally included in the study was 8.3±3.5 years with male to female ratio of 134:66. Atypical features were present in 30 (15%) children; prolonged cholestasis (17, 8.5%), ascites (12, 6%), pleural effusion (4, 2%), thrombocytopenia (2, 1%), and hemolysis (1, 0.5%) were observed. Pruritus (p=0.005), higher serum total and direct bilirubin (p=0.00 and 0.001 respectively), and lower serum albumin (p=0.01) levels were statistically significant in children with atypical manifestations. Moreover, this group had prolonged mean duration of jaundice and hospital course (p=0.00 and 0.083 respectively).

CONCLUSION

Atypical manifestations such as prolonged cholestasis and ascites are not uncommon in children with AVH-A in developing countries and seen in almost one-sixth of patients.

Co-infection of Hepatitis A and Hepatitis E Viruses among the Acute Viral Hepatitis Cases in Tertiary Care Hospital –A Four Years Retrospective Study

Acute viral hepatitis(AVH) is caused by Hepatitis A (HAV) and Hepatitis E(HEV). It is major health burden in India. Both the viruses HAV and HEV are primarily transmitted via the faeco-oral course. Study was conducted to determine the seroprevalence of HAV, HEV and rate of co-infection in AVH patients attending rural tertiary care centre. A retrospective laboratory record based study was carried out in rural tertiary health care center located in Western Maharashtra. Laboratory and Medical records of suspected acute viral infection patients were analyzed during study. Study period was June 2014 to July 2018. Commercially available ELISA kits of IgM anti-HAV and IgM anti-HEV were used to analyze serum samples of suspected study participants. Tests were carried out as per the manufacturer’s instructions. A total of 778 acute viral hepatitis cases were included in the study from July 2014 to July 2018 among which 85/778 (10.9 %) detected positive for HAV and 121/778 (15.6%) detected positive for HEV. Co-infection was identified in 6/778(0.8 %). Jaundice, fever fatigue and hepatomegaly were common clinical presentation in HAV, HEV and confection with both viruses in acute viral hepatitis patients. Study indicated low exposure to HAV in childhood bellow 16 years. Co-infection rate was detected high in 16-25 years age group. Vaccination policy against HAV in adolescent age group needed as there is change epidemiological shift of HAV which has been observed in the current study. These data will helps for planning future vaccination strategies, better implementation sanitation program, and safe water supply in this geographic area.

Role of Granulocyte Colony Stimulating Factor on the Short-Term Outcome of Children with Acute on Chronic Liver Failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) results in very high mortality in children. We aimed to evaluate the role of granulocyte colony-stimulating factor (GCSF) on short-term outcome of children with ACLF in a nontransplant unit.

METHODS

Children (aged > 1 year) diagnosed with ACLF over a 15 month period were randomised. Group A was given GCSF therapy along with standard medical care (SMC - details in supplementary data) and group B was given only SMC. The outcome was evaluated as survival at 30 and 60 days of therapy.

RESULT

Thirty-one children with ACLF were enrolled, with a mean age of 6.92 ± 4.3yrs. A total of 15 patients were randomised to group A and 16 to group B. The overall mortality was 54.83%. The intervention group showed survival rates of 80%, 66.67% and 53.3%, whereas the control group had survival rates of 43.75%, 37.5% and 37.5% at 14, 30 and 60 days, respectively. A significant survival benefit was noted on day 14 (p = 0.043) of therapy in group A with significant difference in Child-Turcotte-Pugh (CTP) and pediatric end-stage liver disease (PELD) scores in the two groups. After an initial rise in group A, the granulocyte counts fell to become comparable in the two groups by day 30 and 60, indicating that the effect of GCSF therapy wears off over time. There was no significant difference in the overall survival, median/mean CTP, PELD and MCS (Modified Cliff sequential organ failure assesment (SOFA)) scores on day 30 and 60. Mean (%) CD 34 + cells level showed a rise on day 7 in group A but was statistically insignificant.

CONCLUSION

The present study shows that GCSF therapy at 5 mcg/kg/day for 5 days seems to be ineffective in improving the survival outcome on day 30 and 60 of therapy. Studies with larger number of children enrolled and longer duration of therapy are required. (CTRI/2017/11/010420).

Need for recognizing atypical manifestations of childhood sporadic acute viral hepatitis warranting differences in management

Various atypical manifestations have been described in acute viral hepatitis (AVH). We evaluated the prevalence, clinical features, response to treatment and outcome of various atypical manifestations of AVH in children. Consecutive children (≤ 18 years) with AVH due to hepatitis A, B, or E were studied while patients with acute or acute on chronic liver failure were excluded. Diagnosis of atypical manifestations was based on standard criteria. A total of 477 children with AVH (median age 7.0 (5-11) years, 74% boys) were seen; 22% (n = 106) had atypical manifestations. Prolonged cholestasis was the most common (11%), followed by ascites (7%), intravascular hemolysis (3%), relapsing hepatitis (2%), acute pancreatitis (1.3%), and thrombocytopenia (0.7%). Atypical manifestations were more common in HAV as compared to HBV (30% vs. 3%, p = 0.00) and HEV (30% vs. 15%, p = 0.07). Prolonged cholestasis was significantly more common in older children (20% in > 10 years vs. 9% in 6-10 years ; p = 0.009 and 5% in 0-5 years of age [p < 0.000]). Ascites was more common in younger children, although not significant. All patients recovered with supportive treatment.Conclusions: Twenty-two percent of children with AVH have atypical manifestations, more often with HAV infection, and prolonged cholestasis is most common. Recognition of these manifestations ensures correct diagnosis and treatment. What is Known: • Acute viral hepatitis is a major public health problem in developing countries. • There is limited information about atypical manifestations which may lead to unnecessary investigations, delayed diagnosis and morbidity. What is New: • Atypical manifestations are common in children, seen most often with HAV infection, and prolonged cholestasis is most common. • Prompt recognition of these manifestations helps in early diagnosis, appropriate management, and preventing unnecessary investigations. • Ensure follow-up until complete recovery and not to miss underlying chronic liver disease.

Coinfection of hepatitis E virus and other hepatitis virus in Colombia and its genotypic characterization

INTRODUCTION

Hepatitis E virus has emerged as a public health problem, particularly in developing countries. The four genotypes identified in mammals include the G3 found in indigenous hepatitis in countries and regions with high porcine population, and the G1, associated with maternal deaths. 

OBJECTIVE

To determine coinfection by hepatitis E virus and the circulating genotypes in Colombia in 1,097 samples using serological markers for hepatitis A, B and C. 

MATERIALS AND METHODS

Serum samples of 1,097 patients from different regions of Colombia stored at the Laboratorio de Virología of the Instituto Nacional de Salud were selected to detect IgG and IgM anti-hepatitis E virus antibodies. The viral genomes of positive samples were amplified by RT-PCR, and the products were sequenced and phylogenetically analyzed by comparing ORF2 sequences deposited in the GenBank. 

RESULTS

IgG anti-hepatitis E virus antibodies were found in 278 samples, IgM in 62, and both markers in 64. Hepatitis E virus and hepatitis A virus coinfection determined by IgG anti-hepatitis E virus was 33.6% and 16.1% by IgM; hepatitis E virus and hepatitis B virus coinfection was 23.4% and 8.1%, and hepatitis E virus and hepatitis C virus coinfection was 35.4% and 5.83%, respectively. Among the 52 positive samples by PCR nine were sequenced and grouped within genotype 3A of the American porcine strain. 

CONCLUSIONS

The highest seropositivity was observed for hepatitis A and E. The incidence of hepatitis E virus coinfection with other hepatotropic viruses indicated that this pathogen is more frequent than expected. The circulation of genotype 3A implies that this disease may occur in outbreaks and as zoonosis in Colombia.

Prevalence of hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus as causes of acute viral hepatitis in North India: a hospital based study

CONTEXT

Acute viral hepatitis (AVH) is a major public health problem and is an important cause of morbidity and mortality.

AIM

The aim of the present study is to determine the prevalence of hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV) and hepatitis E virus (HEV) as causes of AVH in a tertiary care hospital of North India.

SETTINGS AND DESIGN

Blood samples and clinical information was collected from cases of AVH referred to the Grade I viral diagnostic laboratory over a 1-year period.

SUBJECTS AND METHODS

Samples were tested for hepatitis B surface antigen, anti-HCV total antibodies, anti-HAV immunoglobulin M (IgM) and anti-HEV IgM by the enzyme-linked immunosorbent assay. PCR for nucleic acid detection of HBV and HCV was also carried out. Those positive for HBV infection were tested for anti-HDV antibodies.

STATISTICAL ANALYSIS USED

Fisher's exact test was used and a P < 0.05 was considered to be statistically significant.

RESULTS

Of the 267 viral hepatitis cases, 62 (23.22%) patients presented as acute hepatic failure. HAV (26.96%) was identified as the most common cause of acute hepatitis followed by HEV (17.97%), HBV (16.10%) and HCV (11.98%). Co-infections with more than one virus were present in 34 cases; HAV-HEV co-infection being the most common. HEV was the most important cause of acute hepatic failure followed by co-infection with HAV and HEV. An indication towards epidemiological shift of HAV infection from children to adults with a rise in HAV prevalence was seen.

CONCLUSIONS

To the best of our knowledge, this is the first report indicating epidemiological shift of HAV in Uttar Pradesh.

Viral hepatitis in India

Hepatitis in India is caused mainly by hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis E virus (HEV). HAV infection occurs frequently in children, though in parts of India there is an evolving epidemiology. HEV is the most common cause of acute sporadic hepatitis in India and has been associated with several large-scale epidemics in the past. India belongs to the intermediate endemicity zone for HBV carriers. HBV is the major cause of chronic liver disease and liver cancer. Horizontal transmission of HBV plays an important role. Genotypes D, A, and C have been reported in India. HCV is transmitted mainly through suboptimal blood banking and injection practices in India. Genotype 3 is the most predominant, followed by genotype 1.

Coexistence of IgM antihepatitis A virus and IgM antihepatitis E virus in acute viral hepatitis: a prospective, multicentre study in Korea

This study investigated the clinical, serological and molecular characteristics of coexistence of both immunoglobulin M (IgM) antihepatitis A virus (HAV) and IgM antihepatitis E virus (HEV) in acute viral hepatitis using a prospective, multicentre design. Among a total of 771 symptomatic cases with acute viral hepatitis enrolled in a Korean city from September 2006 to August 2008, coexistence of IgM anti-HAV and IgM anti-HEV was found in 43 patients (A+E group; 6%), while the existence of IgM anti-HAV alone was found in 595 patients (A group; 77%) and that of IgM anti-HEV alone in 14 patients (E group; 2%). Clinical data analysis and measurement of IgM and IgG anti-HEV were performed using two different commercial kits, and HAV RNA and HEV RNA were detected in available serum or stool samples. The clinical features of the A+E group were similar to those of the A group. HAV RNA detection rates in the A+E and A group were similar, while HEV RNA was detected only in the stool samples of the E group, not in the A+E group. Comparative testing of anti-HEV using two different ELISA kits showed markedly discordant results for IgM anti-HEV positivity and consistently low positivity for IgG anti-HEV in the A+E group. Coexistence of IgM anti-HEV measured by the Genelabs ELISA kit in the setting of hepatitis A appears to yield false-positive results in nonendemic areas of HEV infection. Diagnosis of hepatitis E using IgM anti-HEV should be made with caution.

Predictors of outcome in acute-on-chronic liver failure in children

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is associated with a high mortality rate in the absence of liver transplantation. There is limited data on predictors of survival in ACLF in children. Therefore, we prospectively studied the predictors of outcome of ACLF in children.

METHODS

A prospective evaluation of 31 children in the age group of 1-16 years who fulfilled the criteria for ACLF according to Asian Pacific Association for the Study of the Liver (APASL) 2008 consensus was done. All consecutive children were evaluated for etiology, diagnosis and severity of ACLF. For grading of organ dysfunction, the sequential organ failure assessment (SOFA) score was calculated. SOFA constitutes the parameters of respiration, coagulation, cardiovascular system, central nervous system, and renal and liver functions. We evaluated possible correlation between outcomes and different variables.

RESULTS

Of the 31 children who fulfilled the criteria for ACLF, the common underlying chronic liver diseases (CLD) were autoimmune hepatitis (AIH) in 41.9% and Wilson disease in 41.9% of the patients. Superinfection with hepatitis A virus (HAV) (41.9%) was the most common etiology of acute deterioration. To find the best predictor for outcome, linear regression analysis was performed. Multivariate analysis revealed that the SOFA score and the International Normalized Ratio (INR) were predictors of survival. Six (19.4%) patients died. Causes of death were multiorgan failure in four and liver failure in two patients.

CONCLUSION

The mortality in ACLF is 19.4% and the causes of death were multiorgan failure and liver failure. The SOFA score and INR were predictors of outcome of ACLF in children.

Concurrent reactivation of latent EBV with hepatitis A can affect clinical feature of childhood hepatitis

AIMS

Some children with acute hepatitis A virus (HAV) infection have concurrent Epstein-Barr virus (EBV) reactivation serologically. We studied the frequency of EBV reactivation during HAV infection and determined whether simultaneous occurrence of EBV reactivation and HAV infection affected the clinical features of HAV infection.

METHODS

The medical records of patients under 19 years of age diagnosed with acute hepatitis A between January 1996 and June 2009 were reviewed.

RESULTS

Among 72 patients with acute hepatitis A, 22 patients (30.6%) had EBV reactivation. A markedly prolonged duration of full recovery from hepatitis was observed in reactivated group. The peak levels of AST and ALT in reactivated group were higher than non-reactivated group (p = 0.012 and p < 0.001, respectively). Higher peak levels of AST and ALT in reactivated subgroups over 10 years old were observed compared to non-reactivated subgroup (p = 0.027 and p = 0.001, respectively). Duration of recovery showed significant differences between two subgroups.

CONCLUSIONS

Concurrent reactivation of latent EBV and HAV infections is common. EBV reactivation with HAV infection adversely affects the clinical feature of hepatitis. Therefore, we should keep in mind that the concurrence especially in older children may cause worse injury to the liver.

Ascitic form of sporadic acute viral hepatitis in children: a distinct entity for recognition

BACKGROUND AND OBJECTIVES

This study looked at the frequency and differences in presentation, laboratory parameters, and outcome between ascitic acute viral hepatitis (AAVH) and nonascitic acute viral hepatitis (NAVH) in children.

METHODS

Diagnosis of AVH was based on clinical features, >3-fold elevation of alanine aminotransferase, viral marker positivity (IgM antihepatitis A virus, IgM antihepatitis E virus, hepatitis B surface antigen, and IgM antihepatitis B core antigen) at presentation, absence of history of liver disease, and subsequent normalization within 6 months of clinical features and liver functions including sustained resolution of ascites in AAVH on follow-up.

RESULTS

A total of 139 children (121 children with NAVH and 18 with AAVH, 12.9%) were studied. Children with AAVH in comparison with those with NAVH were younger (median age 4 vs 8 years), had lower frequency of prodrome (22% vs 51%), lower serum albumin (median 2.8 vs 3.7 g/dL), low total serum protein (median 6.5 vs 7.4 g/dL), and prolongation of prothrombin time (median 4.8 vs 1.05 seconds); all P < 0.03. No significant differences were found in sex, height standard deviation scores, duration of symptoms, liver span or consistency, transaminases, alkaline phosphatase, and etiology of NAVH versus AAVH. Among the AAVH group clinically detectable ascites was present in 38.9% (7/18), spontaneous bacterial peritonitis in 11%, and diuretics had to be used in 44% of cases. Ascites resolved in all of the cases in 8 weeks (94.4% cases in <4 weeks) and liver functions normalized in 17%, 50%, and 33% cases in <4, 4 to 8, and >8 weeks duration, respectively.

CONCLUSIONS

We report AAVH as a distinct entity that affects younger children. This subgroup has compromised biosynthetic liver functions irrespective of viral etiology with total recovery.