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Tan CCS, Kelly G, Cregan J, Wilson JD, James T, Chand M, Hopkins S, Swets M, Baillie JK, Jeffery K, Walker AS, Eyre DW, Stoesser N, Matthews PC. Retrospective analysis of hospital electronic health records reveals unseen cases of acute hepatitis with unknown aetiology in adults in Oxfordshire. BMC Public Health 2024; 24:1890. [PMID: 39010057 PMCID: PMC11251388 DOI: 10.1186/s12889-024-19292-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 06/27/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND An outbreak of acute severe hepatitis of unknown aetiology (AS-Hep-UA) in children during 2022 was subsequently linked to infections with adenovirus-associated virus 2 and other 'helper viruses', including human adenovirus. It is possible that evidence of such an outbreak could be identified at a population level based on routine data captured by electronic health records (EHR). METHODS We used anonymised EHR to collate retrospective data for all emergency presentations to Oxford University Hospitals NHS Foundation Trust in the UK, between 2016-2022, for all ages from 18 months and older. We investigated clinical characteristics and temporal distribution of presentations of acute hepatitis and of adenovirus infections based on laboratory data and clinical coding. We relaxed the stringent case definition adopted during the AS-Hep-UA to identify all cases of acute hepatitis with unknown aetiology (termed AHUA). We compared events within the outbreak period (defined as 1st Oct 2021-31 Aug 2022) to the rest of our study period. RESULTS Over the study period, there were 903,433 acute presentations overall, of which 391 (0.04%) were classified as AHUA. AHUA episodes had significantly higher critical care admission rates (p < 0.0001, OR = 41.7, 95% CI:26.3-65.0) and longer inpatient admissions (p < 0.0001) compared with the rest of the patient population. During the outbreak period, significantly more adults (≥ 16 years) were diagnosed with AHUA (p < 0.0001, OR = 3.01, 95% CI: 2.20-4.12), and there were significantly more human adenovirus (HadV) infections in children (p < 0.001, OR = 1.78, 95% CI:1.27-2.47). There were also more HAdV tests performed during the outbreak (p < 0.0001, OR = 1.27, 95% CI:1.17-1.37). Among 3,707 individuals who were tested for HAdV, 179 (4.8%) were positive. However, there was no evidence of more acute hepatitis or increased severity of illness in HadV-positive compared to negative cases. CONCLUSIONS Our results highlight an increase in AHUA in adults coinciding with the period of the outbreak in children, but not linked to documented HAdV infection. Tracking changes in routinely collected clinical data through EHR could be used to support outbreak surveillance.
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Affiliation(s)
- Cedric C S Tan
- The Francis Crick Institute, London, UK
- UCL Genetics Institute, University College London, London, UK
| | - Gavin Kelly
- Bioinformatics and Biostatistics, The Francis Crick Institute, London, UK
| | - Jack Cregan
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Joseph D Wilson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Tim James
- Department of Biochemistry, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Meera Chand
- United Kingdom Health Security Agency, Colindale, UK
| | - Susan Hopkins
- NIHR Health Protection Research Unit, Imperial College London, London, UK
| | - Maaike Swets
- Leiden University Medical Center, Leiden, Netherlands
| | | | - Katie Jeffery
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - David W Eyre
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals, Oxford, UK
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicole Stoesser
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals, Oxford, UK
| | - Philippa C Matthews
- The Francis Crick Institute, London, UK.
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- University College London Hospitals NHS Foundation Trust, London, UK.
- University College London, London, UK.
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2
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Almendares O, Baker JM, Sugerman DE, Parashar UD, Reagan-Steiner S, Kirking HL, Gastañaduy PA, Tate JE. Deaths Associated with Pediatric Hepatitis of Unknown Etiology, United States, October 2021-June 2023. Emerg Infect Dis 2024; 30. [PMID: 38526164 PMCID: PMC10977843 DOI: 10.3201/eid3004.231140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
During October 2021-June 2023, a total of 392 cases of acute hepatitis of unknown etiology in children in the United States were reported to Centers for Disease Control and Prevention as part of national surveillance. We describe demographic and clinical characteristics, including potential involvement of adenovirus in development of acute hepatitis, of 8 fatally ill children who met reporting criteria. The children had diverse courses of illness. Two children were immunocompromised when initially brought for care. Four children tested positive for adenovirus in multiple specimen types, including 2 for whom typing was completed. One adenovirus-positive child had no known underlying conditions, supporting a potential relationship between adenovirus and acute hepatitis in previously healthy children. Our findings emphasize the importance of continued investigation to determine the mechanism of liver injury and appropriate treatment. Testing for adenovirus in similar cases could elucidate the role of the virus.
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3
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Rodriguez-Frias F, Rando-Segura A, Quer J. Solved the enigma of pediatric severe acute hepatitis of unknown origin? Front Cell Infect Microbiol 2023; 13:1175996. [PMID: 37808908 PMCID: PMC10552268 DOI: 10.3389/fcimb.2023.1175996] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Hepatitis is an inflammation of the liver whose etiology is very heterogeneous. The most common cause of hepatitis is viral infections from hepatotropic viruses, including hepatitis A, B, C, D and E. However, other factors such as infections from other agents, metabolic disorders, or autoimmune reactions can also contribute to hepatitis, albeit to a lesser extent. On April 5, 2022, the United Kingdom Health Security Agency alerted the World Health Organization (WHO) on the increased incidence of severe acute hepatitis of unknown causes (not A-E) in previously healthy young children, with symptoms of liver failure that in some cases required liver transplantation. By July 2022, 1,296 cases were reported in 37 countries. Acute hepatitis of unknown causes is not an exceptional phenomenon: in fact, it represents more than 30% of cases of acute hepatitis in children, however in the present instance the large proportion of severe cases was surprising and alarming (6% of liver transplants and almost 3% mortality). Multiple hypotheses have been proposed to explain the etiology of such higher proportion of acute hepatitis, including their co-occurrence in the context of COVID-19 pandemic. This is a review of the history of a clinical threat that has put in check a world health care system highly sensitized by the current COVID-19 pandemics, and that it looks like has ended with the arguments that the severe acute pediatric hepatitis is caused by Adeno-associated virus 2 (AAV2) infection associated with a coinfection with a helper virus (human Adenovirus HAdV or human herpesvirus 6) in susceptible children carrying HLA-class II antigen HLA-DRB1*04:01.
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Affiliation(s)
- Francisco Rodriguez-Frias
- Clinical Biochemistry Department Vall d’Hebron Institut of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Basic Science Department, International University of Catalonia, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Ariadna Rando-Segura
- Clinical Biochemistry Department Vall d’Hebron Institut of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Josep Quer
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Liver Diseases-Viral Hepatitis, Liver Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Biochemistry and Molecular Biology Department, Autonomous University of Barcelona (UAB), Barcelona, Spain
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4
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Elsheikh R, Tien HT, Makram AM, Van NT, Le TTB, Vasanthakumaran T, Huy NT. Acute hepatitis of unknown origin in children: Behind the statistics. Hepatology 2023; 77:2118-2127. [PMID: 35862247 DOI: 10.1002/hep.32682] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 01/05/2023]
Abstract
Since April 2022, the world has been witnessing a rapidly spreading outbreak of acute hepatitis of unknown origin in children < 16 years old that has affected several countries around the world. Most of the cases have presented with the clinical picture of severe hepatitis that has led to resorting to liver transplantation in several cases. Despite the numerous theories that have been suggested on the possible underlying etiologies of the outbreak, an association with hepatitis A-E viruses and a link to COVID-19 vaccines have been excluded. Adenovirus serotype 41 has been detected in numerous cases, which makes it the most likely underlying cause of the disease. Nevertheless, other hypotheses are being investigated to justify the severity of the clinical picture, which is not typical of this type of virus. This review aims to summarize the current knowledge about the outbreak, highlight the suggested working hypotheses, and report the public health measures undertaken to tackle the outbreak.
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Affiliation(s)
- Randa Elsheikh
- Faculty of Medicine , October 6 University , Giza , Egypt
- Online Research Club , Nagasaki , Japan
| | - Hoang Thuy Tien
- Online Research Club , Nagasaki , Japan
- Faculty of Pharmacy , Da Nang University of Medical Technology and Pharmacy , Da Nang , Vietnam
| | - Abdelrahman M Makram
- Faculty of Medicine , October 6 University , Giza , Egypt
- Online Research Club , Nagasaki , Japan
- School of Public Health , Imperial College London , London , UK
| | - Nguyen Thanh Van
- Online Research Club , Nagasaki , Japan
- Global Clinical Scholars Research Training , Harvard Medical School , Boston , Massachusetts , USA
| | - Trang Thi Bich Le
- Online Research Club , Nagasaki , Japan
- University of Medicine and Pharmacy at Ho Chi Minh City , Ho Chi Minh City , Vietnam
| | - Tamilarasy Vasanthakumaran
- Online Research Club , Nagasaki , Japan
- Global Clinical Scholars Research Training , Harvard Medical School , Boston , Massachusetts , USA
| | - Nguyen Tien Huy
- Online Research Club , Nagasaki , Japan
- School of Tropical Medicine and Global Health , Nagasaki University , Nagasaki , Japan
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5
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Elbeltagi R, Al-Beltagi M, Saeed NK, Bediwy AS, Toema O. May 2022 acute hepatitis outbreak, is there a role for COVID-19 and other viruses? World J Hepatol 2023; 15:364-376. [PMID: 37034240 PMCID: PMC10075009 DOI: 10.4254/wjh.v15.i3.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/06/2023] [Accepted: 03/14/2023] [Indexed: 03/24/2023] Open
Abstract
There has been an increasing number of reported cases of acute hepatitis of unknown origin in previously healthy children since first reported on March 31, 2022. This clinical syndrome is identified by jaundice and markedly elevated liver enzymes with increased aspartate transaminase and/or alanine aminotransaminase (greater than 500 IU/L). We conducted an inclusive literature review with respect to acute hepatitis outbreaks in children using the search terms acute hepatitis, outbreak, children, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), coronavirus disease 2019 (COVID-19), and adenovirus. According to the cumulative data presented in four main studies, the median age is 4 years, with a male predominance (1.3:1). Jaundice was the most common clinical manifestation (69%), followed by vomiting (63%), anorexia (52.9%), diarrhea (47.2%), abdominal pain (39%), pyrexia (33.3%), pale stool (30%), and dark urine (30%). Coryza and lethargy were reported in 16.6%, while pruritus was reported in 2% of cases. Acute liver failure was observed in 25% of cases. The exact mechanism of this acute hepatitis outbreak is still not entirely clear. Adenoviruses and SARS-CoV-2 were detected in a significant number of patients. Coinfection with adenovirus and SARS-CoV-2 could be a possible underlying mechanism. However, other possible infections and mechanisms must be considered in the pathogenesis of this condition. Acute hepatitis of unknown origin in children has been a serious problem since the start of the COVID-19 pandemic but has not yet been sufficiently addressed. Many questions remain regarding the underlying mechanisms leading to acute liver failure in children, and it is likely that extensive future research is needed.
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Affiliation(s)
- Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
| | - Mohammed Al-Beltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Al Gharbia, Egypt
- Department of Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Department of Pathology, Microbiology Section, Salmaniya Medical Complex, Manama 12, Bahrain
- Department of Microbiology, Royal College of Surgeons in Ireland - Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Diseases, Faculty of Medicine, Tanta University, Tanta 31527, Al Gharbia, Egypt
- Department of Chest Diseases, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Osama Toema
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Al Gharbia, Egypt
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6
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Pan L, Sun L, Asakawa T, Ben X, Lu H. Updated information regarding acute severe hepatitis of unknown origin in children: Viewpoints of and insights from pediatricians. Biosci Trends 2023; 17:68-72. [PMID: 36273891 DOI: 10.5582/bst.2022.01438] [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: 11/09/2022]
Abstract
Recently, the morbidity of acute severe hepatitis of unknown origin in children (SHIC) has tended to decrease, but this condition should not be ignored because of its uncertain but severe nature. The current study briefly summarizes updated information regarding the epidemiological, clinical, and etiological aspects of SHIC based on the newest information available. Opinions from pediatricians are also presented. In light of the status quo of SHIC and COVID-19 globally, several suggestions are proposed to improve future studies, which could help to further explore the underlying mechanisms of SHIC in the context of COVID-19.
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Affiliation(s)
- Liping Pan
- Department of Pediatrics, Third People's Hospital of Shenzhen, Shenzhen, Guangdong, China
| | - Lulu Sun
- Department of Pediatrics, Third People's Hospital of Shenzhen, Shenzhen, Guangdong, China
| | - Tetsuya Asakawa
- Institute of Neurology, Third People's Hospital of Shenzhen, Shenzhen, Guangdong, China
| | - Xiaoming Ben
- Department of Pediatrics, Third People's Hospital of Shenzhen, Shenzhen, Guangdong, China
| | - Hongzhou Lu
- Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Third People's Hospital of Shenzhen, Shenzhen, Guangdong, China
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7
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Patel N, Sethi Y, Kaka N, Kaiwan O, Gupta I, Shaheen RS, Sapoor S, Chopra H, Popoviciu MS, Emran TB, Cavalu S. Acute Hepatitis of Unknown Origin in Pediatric Age Group: Recent Outbreaks and Approach to Management. J Clin Med 2022; 12:9. [PMID: 36614809 PMCID: PMC9821143 DOI: 10.3390/jcm12010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Acute hepatitis has always been a public health concern, but the recent clustering of cases in various parts of the world has drawn some special attention. The sudden rise in cases has mainly been among the pediatric population of around 35 countries around the world, including developed countries such as the United States, the United Kingdom, and European countries. The outbreaks have had a devastating impact, with around 10% of the affected patients developing liver failure. The clinical presentation of patients resembles any other case of acute hepatitis, with the major symptoms being: jaundice (68.8%), vomiting (57.6%), and gastrointestinal symptoms such as abdominal pain (36.1%) and nausea (25.7%). Interestingly, the cases have tested negative for hepatotropic viruses Hep A, B, C, and E, thus giving rise to the terms Hepatitis of Unknown Origin or non-HepA-E hepatitis. Many causes have been attributed to the disease, with major evidence seen for adenovirus and SARS-CoV-2. International agencies have stressed on establishing diagnostic and management protocols to limit these outbreaks. As the understanding has evolved over time, diagnostic and management faculties have found more shape. The current review was designed to comprehensively compile all existing data and whittle it down to evidence-based conclusions to help clinicians.
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Affiliation(s)
- Neil Patel
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Yashendra Sethi
- PearResearch, Dehradun 248001, India
- Department of Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun 248001, India
| | - Nirja Kaka
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Oroshay Kaiwan
- PearResearch, Dehradun 248001, India
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA
| | - Ishita Gupta
- PearResearch, Dehradun 248001, India
- Department of Medicine, Dr. Rajendra Prasad Government Medical College, Tanda 176001, India
| | - Rahma Sameh Shaheen
- PearResearch, Dehradun 248001, India
- Faculty of Medicine, Benha University, Banha 6470031, Egypt
| | - Shady Sapoor
- PearResearch, Dehradun 248001, India
- Faculty of Medicine, Benha University, Banha 6470031, Egypt
| | - Hitesh Chopra
- Department of Pharmacy, Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India
| | - Mihaela Simona Popoviciu
- Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410087 Oradea, Romania
| | - Talha Bin Emran
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh
| | - Simona Cavalu
- Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410087 Oradea, Romania
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8
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Zhong R, Yi F, Xiang F, Qiu YF, Zhu L, Zou YH, Wang W, Zhang Q. Hepatitis of unknown etiology in children: Current evidence and association. World J Clin Cases 2022; 10:12837-12843. [PMID: 36569007 PMCID: PMC9782959 DOI: 10.12998/wjcc.v10.i35.12837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/13/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
Two years after the coronavirus disease 2019 (COVID-19) pandemic, acute hepatitis of unknown etiology in children (AHUCD) began to be reported worldwide. The novel coronavirus and adenovirus were found in pathogen and antibody tests in AHUCD cases reported by the World Health Organization. Children are not exposed to the viruses that children are generally exposed to owing to COVID-19 infection preventive measures such as isolation and wearing masks; therefore, some researchers have speculated that this disease is related to reduced exposure to pathogens. Some scientists have also speculated that the disease is related to liver injury and adenoviral hepatitis, which are the sequelae of COVID-19. Some evidence also suggests a weak association between the disease and COVID-19 vaccination. Therefore, further research and investigation of the pathogenesis, preventive measures, and early treatment of hepatitis of unknown etiology are required. This study aimed to synthesize available evidence to further elucidate this disease in order to treat and prevent it effectively.
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Affiliation(s)
- Rui Zhong
- Department of Medical Oncology, Digestive and Urinary Unit, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Feng Yi
- Department of Emergency, Yueyang Central Hospital, Yueyang 414100, Hunan Province, China
| | - Fen Xiang
- Department of Emergency, Yueyang Central Hospital, Yueyang 414100, Hunan Province, China
| | - Yan-Fang Qiu
- Department of Radiation Therapy Oncology, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Lei Zhu
- School of Nursing, Hunan University of Chinese Medicine, Changsha 410208, Hunan Province, China
| | - Yan-Hui Zou
- Health Service Centre, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Wei Wang
- Department of Medical Oncology, Digestive and Urinary Unit, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Qiong Zhang
- Department of Emergency, Yueyang Central Hospital, Yueyang 414100, Hunan Province, China
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9
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Matthews PC, Campbell C, Săndulescu O, Matičič M, Ruta SM, Rivero-Juárez A, van Welzen BJ, Tan BK, Garcia F, Gherlan GS, Çınar G, Hasanoğlu İ, Gmizić I, Nicolini LA, Santos L, Sargsyants N, Velikov P, Habibović S, Fourati S, Židovec-Lepej S, Herder V, Dudman S, Miron VD, Irving W, Şahin GÖ. Acute severe hepatitis outbreak in children: A perfect storm. What do we know, and what questions remain? Front Pharmacol 2022; 13:1062408. [PMID: 36506522 PMCID: PMC9732095 DOI: 10.3389/fphar.2022.1062408] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
During the first half of 2022, the World Health Organization reported an outbreak of acute severe hepatitis of unknown aetiology (AS-Hep-UA) in children, following initial alerts from the United Kingdom (UK) where a cluster of cases was first observed in previously well children aged <6 years. Sporadic cases were then reported across Europe and worldwide, although in most countries incidence did not increase above the expected baseline. There were no consistent epidemiological links between cases, and microbiological investigations ruled out known infectious causes of hepatitis. In this review, we explore the evidence for the role of viral infection, superimposed on a specific host genetic background, as a trigger for liver pathology. This hypothesis is based on a high prevalence of Human Adenovirus (HAdV) 41F in affected children, together with metagenomic evidence of adeno-associated virus (Adeno-associated viruses)-2, which is a putative trigger for an immune-mediated liver injury. Roles for superantigen-mediated pathology have also been explored, with a focus on the potential contribution of SARS-CoV-2 infection. Affected children also had a high frequency of the MHC allele HLA-DRB1*04:01, supporting an immunological predisposition, and may have been vulnerable to viral coinfections due to disruption in normal patterns of exposure and immunity as a result of population lockdowns during the COVID-19 pandemic. We discuss areas of ongoing uncertainty, and highlight the need for ongoing scrutiny to inform clinical and public health interventions for this outbreak and for others that may evolve in future.
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Affiliation(s)
- Philippa C. Matthews
- The Francis Crick Institute, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
- Department of Infection, University College London Hospitals, London, United Kingdom
| | - Cori Campbell
- Nuffield Department of Medicine, University of Oxford, Oxford, England
| | - Oana Săndulescu
- Department of Infectious Diseases, National Institute for Infectious Diseases-Prof. Dr. Matei Balş, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mojca Matičič
- Faculty of Medicine, Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - Simona Maria Ruta
- Virology Department, Stefan S. Nicolau Institute of Virology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Antonio Rivero-Juárez
- Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - Berend Joost van Welzen
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Boun Kim Tan
- INSERM U1052, Department of Intensive Care Unit, Hôpital Lyon Sud, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Federico Garcia
- Microbiology Department, Instituto de Investigacion Ibs.Granada and Ciber de Enfermedades Infecciosas (CIBERINFEC), University Hospital San Cecilio, Granada, Spain
| | - George Sebastian Gherlan
- Department of Infectious Diseases, “Dr. Victor Babes” Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania
| | - Güle Çınar
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - İmran Hasanoğlu
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Ivana Gmizić
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Belgrade, Serbia
| | - Laura Ambra Nicolini
- Division of Infectious Diseases , Ospedale Policlinico San Martino, Genova, Italy
| | - Lurdes Santos
- Nephrology and Infectious Diseases R&D, Infectious Diseases Intensive Care Unit, Faculty of Medicine of University of Porto, Centro Hospitalar Universitário São João, I3S - Instituto de Investigação e Inovaçãoem Saúde, University of Porto, Porto, Portugal
| | - Narina Sargsyants
- Ministry of Health, National Centre for Infectious Diseases, National Institute of Health, Yerevan, Armenia
| | - Petar Velikov
- Infectious Diseases Hospital Prof. Ivan Kirov and Department of Infectious Diseases, Parasitology and Tropical Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Selma Habibović
- Department of Microbiology, Public Health Institute Novi Pazar, Novi Pazar, Serbia
| | - Slim Fourati
- Department of Virology, INSERM, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Institut Mondor de Recherche Biomédicale, Université Paris-Est, Créteil, France
| | - Snježana Židovec-Lepej
- Department of Immunological and Molecular Diagnostics, University Hospital for Infectious Diseases “Dr Fran Mihaljevic”, Zagreb, Croatia
| | - Vanessa Herder
- Medical Research Council-University of Glasgow Centre for Virus Research, University of Glasgow, Glasgow, United Kingdom
| | - Susanne Dudman
- Department of Microbiology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Victor Daniel Miron
- National Institute for Mother and Child Health “Alessandrescu-Rusescu”, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - William Irving
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Gülşen Özkaya Şahin
- Department of Laboratory Medicine, Section of Clinical Microbiology, Region Skåne, Lund, Sweden
- Department of Translational Medicine, Lund University, Malmö, Sweden
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10
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Chandok N, Yoshida EM. The acute hepatitis outbreak in children in 2022: The story so far. CANADIAN LIVER JOURNAL 2022; 5:439-440. [PMID: 38144404 PMCID: PMC10735192 DOI: 10.3138/canlivj-2022-09-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Affiliation(s)
- Natasha Chandok
- Division of Gastroenterology, William Osler Health System, Brampton, Ontario, Canada
| | - Eric M Yoshida
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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