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Terebuh P, Olaker VR, Kendall EK, Kaelber DC, Xu R, Davis PB. Liver abnormalities following SARS-CoV-2 infection in children 1 to 10 years of age. Fam Med Community Health 2024; 12:e002655. [PMID: 38272541 PMCID: PMC10824054 DOI: 10.1136/fmch-2023-002655] [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] [Indexed: 01/27/2024] Open
Abstract
OBJECTIVE Beginning in October 2021 in the USA and elsewhere, cases of severe paediatric hepatitis of unknown aetiology were identified in young children. While the adenovirus and adenovirus-associated virus have emerged as leading aetiological suspects, we attempted to investigate a potential role for SARS-CoV-2 in the development of subsequent liver abnormalities. DESIGN We conducted a study using retrospective cohorts of deidentified, aggregated data from the electronic health records of over 100 million patients contributed by US healthcare organisations. RESULTS Compared with propensity score matched children with other respiratory infections, children aged 1-10 years with COVID-19 had a higher risk of elevated transaminases (HR (95% CI) 2.16 (1.74 to 2.69)) or total bilirubin (HR (95% CI) 3.02 (1.91 to 4.78)), or new diagnoses of liver diseases (HR (95% CI) 1.67 (1.21 to 2.30)) from 1 to 6 months after infection. Patients with pre-existing liver abnormalities, liver abnormalities surrounding acute infection, younger age (1-4 years) or illness requiring hospitalisation all had similarly elevated risk. Children who developed liver abnormalities following COVID-19 had more pre-existing conditions than those who developed abnormalities following other infections. CONCLUSION These results indicate that SARS-CoV-2 may prime the patient for subsequent development of liver infections or non-infectious liver diseases. While rare (~1 in 1000), SARS-CoV-2 is a risk for subsequent abnormalities in liver function or the diagnosis of diseases of the liver.
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Affiliation(s)
- Pauline Terebuh
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University, Cleveland, OH, USA
| | - Veronica R Olaker
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University, Cleveland, OH, USA
| | - Ellen K Kendall
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University, Cleveland, OH, USA
| | - David C Kaelber
- The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
- Department of Medicine, Pediatrics, Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Rong Xu
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University, Cleveland, OH, USA
| | - Pamela B Davis
- Center for Community Health Integration, Case Western Reserve University, Cleveland, OH, USA
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Phan J, Eslick GD, Elliott EJ. Demystifying the global outbreak of severe acute hepatitis of unknown aetiology in children: A systematic review and meta-analysis. J Infect 2024; 88:2-14. [PMID: 38007049 DOI: 10.1016/j.jinf.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND The sudden outbreak of severe acute hepatitis of unknown aetiology (SAHUA) in the first half of 2022 affected more than 1010 children in 35 countries worldwide. Dire clinical outcomes, such as acute liver failure necessitating transplantation, neurological symptoms, long-term sequelae, and death, highlight the need to determine the pathogenesis of this condition. Hypotheses on the aetiology include adenovirus and SARS-CoV-2 infections and an aberrant immune response to multiple pathogen exposure following lifting of lockdown measures but further investigation is required to reach an informed consensus. METHODS A literature search was performed on MEDLINE and EMBASE in accordance with PRISMA guidelines for systematic reviews. Primary studies reporting data on severe acute hepatitis of unknown aetiology in children from the COVID-19 era were selected for inclusion in our review. Data on patient demographics, clinical presentation and outcomes, and diagnostic testing for coinfection were extracted. Meta-analysis used a random-effects model. RESULTS The 33 included studies (30 case series and 3 case-control studies) described a total of 3636 cases of SAHUA (reported 1 January, 2019-31 December, 2022), with a median age of 3.5 years. Of these, 214 children (5.9%) received a liver transplant and 66 (1.8%) died. Whilst data on diagnostic testing was incomplete, the most frequently detected coinfections were with adenovirus and/or adeno-associated virus 2 (AAV2). Other common childhood respiratory and enteric pathogens, such as enterovirus, rhinovirus, and herpesviruses (EBV and HHV-6), were also identified. CONCLUSION Coinfection with AAV2 and other common childhood pathogens may predispose children to develop this novel severe hepatitis. Altered susceptibility and response to such pathogens may be a consequence of immunological naivety following pandemic restrictions. Further investigations are needed to generate high-quality evidence on aetiology for different patient demographics and geographical areas.
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Affiliation(s)
- Julie Phan
- The Australian Paediatric Surveillance Unit [APSU], The Kids Research Institute, The Children's Hospital, Westmead, Westmead, New South Wales, Australia
| | - Guy D Eslick
- The Australian Paediatric Surveillance Unit [APSU], The Kids Research Institute, The Children's Hospital, Westmead, Westmead, New South Wales, Australia.
| | - Elizabeth J Elliott
- The Australian Paediatric Surveillance Unit [APSU], The Kids Research Institute, The Children's Hospital, Westmead, Westmead, New South Wales, Australia
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Lee KJ, Ko JS, Park KY, Kang KS, Lee K, Hong J, Kim SC, Lee Y, Kang B, Kim YB, Kim HJ, Eun BW, Cho HK, Kim YJ, Kim MJ, Lee J, Lee TJ, Oh SH, Park S, Hwang EH, Sohn S, Lim JG, Kim Y, Lee YJ. A Report on a Nationwide Surveillance System for Pediatric Acute Hepatitis of Unknown Etiology in Korea. J Korean Med Sci 2023; 38:e401. [PMID: 38050913 PMCID: PMC10695753 DOI: 10.3346/jkms.2023.38.e401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/07/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Several cases of pediatric acute hepatitis of unknown etiology related to adenoviral infections have been reported in Europe since January 2022. The aim of this study was to compare the incidence, severity, possible etiology, and prognosis of the disease with those in the past in Korea. METHODS The surveillance group collected data between May and November 2022 using a surveillance system. Acute hepatitis of unknown etiology was defined in patients aged < 16 years with a serum transaminase level > 500 IU/L, not due to hepatitis A-E or other underlying causes. For comparison, data from 18 university hospitals were retrospectively collected as a control group between January 2021 and April 2022. RESULTS We enrolled 270 patients (mean age, 5 years). The most common symptom was fever. However, the incidence was similar between 2021 and 2022. Liver function test results, number of patients with acute liver failure (ALF), liver transplantation (LT), death, and adenovirus detection rates did not differ between the two groups. None of the adenovirus-positive patients in either group experienced ALF, LT, or death. In the surveillance group, adenovirus-associated virus-2 was detected in four patients, one of whom underwent LT. Patients with an unknown etiology showed significantly higher bilirubin levels, a lower platelet count, and a higher LT rate than patients with a possible etiology. CONCLUSION The incidence of pediatric acute hepatitis of unknown etiology and adenovirus detection rate have not increased in Korea.
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Affiliation(s)
- Kyung Jae Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Kie Young Park
- Department of Pediatrics, Gangneung Asan Hospital, College of Medicine, Ulsan University, Gangneung, Korea
| | - Ki Soo Kang
- Department of Pediatrics, Jeju National University Hospital, Jeju, Korea
| | - Kunsong Lee
- Department of Pediatrics, Dankook University Hospital, Cheonan, Korea
| | - Jeana Hong
- Department of Pediatrics, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Soon Chul Kim
- Department of Pediatrics, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Yoon Lee
- Department of Pediatrics, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Children's Hospital, Daegu, Korea
| | - Yu Bin Kim
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Jin Kim
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Byung Wook Eun
- Department of Pediatrics, Eulji University Eulji General Hospital, Seoul, Korea
| | - Hye-Kyung Cho
- Department of Pediatrics, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Jin Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Lee
- Department of Pediatrics, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Taek-Jin Lee
- Department of Pediatrics, CHA University School of Medicine, Pocheon, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Sowon Park
- Department of Pediatrics, Severance Children's Hospital, Severance Pediatric Liver Research Group, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Ha Hwang
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Sangjun Sohn
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jin Gyu Lim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - YooJin Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yeoun Joo Lee
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea.
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Powell EA, Hata DJ, Starolis MW. Viral pathogen detection using multiplex gastrointestinal molecular panels: The pros and cons of viral target inclusion. J Clin Virol 2023; 169:105612. [PMID: 37866093 DOI: 10.1016/j.jcv.2023.105612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/31/2023] [Accepted: 10/14/2023] [Indexed: 10/24/2023]
Abstract
Diagnosis of gastrointestinal infections has been revolutionized by the development of in vitro diagnostic (IVD) multiplex molecular panels for the detection of viral nucleic acids. In addition to a high degree of accuracy, these panels are commercially available and relatively simple to perform in the clinical laboratory. However, use of these panels must be carefully considered owing to the laboratory costs of the test, limited reimbursement, and potential for overuse. In this review from the Pan American Society for Clinical Virology, we focus on the viral components of GI multiplex panels (GIPs), presenting a brief overview of pathogens included on most panels and a discussion of advantages and challenges of the inclusion of viral targets on GIPs that should be considered before implementation in the clinical laboratory.
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Affiliation(s)
- Eleanor A Powell
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, 234 Goodman St., Cincinnati, OH 45219, United States.
| | - D Jane Hata
- Department of Laboratory Medicine and Pathology, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32266, United States
| | - Meghan W Starolis
- Quest Diagnostics, 14225 Newbrook Dr., Chantilly, VA 20155, United States
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5
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Cates J, Baker JM, Almendares O, Balachandran N, McKeever ER, Kambhampati AK, Cubenas C, Vinjé J, Cannon JL, Chhabra P, Freeman B, Reagan-Steiner S, Bhatnagar J, Gastañaduy PA, Kirking HL, Sugerman D, Parashar UD, Tate JE. Paediatric acute hepatitis of unknown aetiology: a national surveillance investigation in the USA during 2021 and 2022. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:773-785. [PMID: 37774732 PMCID: PMC11088931 DOI: 10.1016/s2352-4642(23)00192-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/26/2023] [Accepted: 07/13/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Adenovirus is a known cause of hepatitis in immunocompromised children, but not in immunocompetent children. In April, 2022, following multiple reports of hepatitis of unknown aetiology and adenovirus viraemia in immunocompetent children in the USA and UK, the US Centers for Disease Control and Prevention (CDC) and jurisdictional health departments initiated national surveillance of paediatric acute hepatitis of unknown aetiology. We aimed to describe the clinical and epidemiological characteristics of children identified with hepatitis of unknown aetiology between Oct 1, 2021, and Sept 30, 2022, in the USA and to compare characteristics of those who tested positive for adenovirus with those who tested negative. METHODS In this national surveillance investigation in the USA, children were identified for investigation if they were younger than 10 years with elevated liver transaminases (>500 U/L) who had an unknown cause for their hepatitis and onset on or after Oct 1, 2021. We reviewed medical chart abstractions, which included data on demographics, underlying health conditions, signs and symptoms of illness, laboratory results, vaccination history, radiological and liver pathology findings, diagnoses and treatment received, and outcomes. Caregiver interviews were done to obtain information on symptoms and health-care utilisation for the hepatitis illness, medical history, illness in close contacts or at school or daycare, diet, travel, and other potential exposures. Blood, stool, respiratory, and tissue specimens were evaluated according to clinician discretion and available specimens were submitted to CDC for additional laboratory testing or pathology evaluation. FINDINGS Surveillance identified 377 patients from 45 US jurisdictions with hepatitis of unknown aetiology with onset from Oct 1, 2021, to Sept 30, 2022. The median age of patients was 2·8 years (IQR 1·2-5·0) and 192 (51%) were male, 184 (49%) were female, and one patient had sex unknown. Only 22 (6%) patients had a notable predisposing underlying condition. 347 patients (92%) were admitted to hospital, 21 (6%) subsequently received a liver transplant, and nine (2%) died. Among the 318 patients without notable underlying conditions, 275 were tested for adenovirus. Of these 116 (42%) had at least one positive specimen, and species F type 41 was the most frequent type identified (19 [73%] of 26 typed specimens were HAdV-41). Proportions of patients who had acute liver failure, received a liver transplant, and died were similar between those who tested positive for adenovirus compared with those who tested negative. Adenovirus species F was detected by polymerase chain reaction in nine pathology liver evaluations, but not by immunohistochemistry in seven of the nine with adequate liver tissue available. Interviews with caregivers yielded no common exposures. INTERPRETATION Adenovirus, alone or in combination with other factors, might play a potential role in acute hepatitis among immunocompetent children identified in this investigation, but the pathophysiologic mechanism of liver injury is unclear. To inform both prevention and intervention measures, more research is warranted to determine if and how adenovirus might contribute to hepatitis risk and the potential roles of other pathogens and host factors. FUNDING None.
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Affiliation(s)
- Jordan Cates
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Julia M Baker
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Olivia Almendares
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Neha Balachandran
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Cherokee Nation Assurance, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Erin R McKeever
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anita K Kambhampati
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Caelin Cubenas
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jan Vinjé
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer L Cannon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; CDC Foundation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Preeti Chhabra
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brandi Freeman
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sarah Reagan-Steiner
- National Center for Immunization and Respiratory Diseases; Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Julu Bhatnagar
- National Center for Immunization and Respiratory Diseases; Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Paul A Gastañaduy
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hannah L Kirking
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David Sugerman
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jacqueline E Tate
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Mandal S, Simmons R, Ireland G, Charlett A, Desai M, Coughlan L, Powell A, Leeman D, Williams C, Neill C, O'Leary MC, Sawyer C, Rowley F, Harris C, Houlihan C, Gordon C, Rampling T, Callaby H, Hoschler K, Cogdale J, Renz E, Sebastianpilli P, Thompson C, Talts T, Celma C, Davies EA, Ahmad S, Machin N, Gifford L, Moore C, Dickson EM, Divala TH, Henderson D, Li K, Broadbent P, Ushiro-Lumb I, Humphreys C, Grammatikopoulos T, Hartley J, Kelgeri C, Rajwal S, Okike I, Kelly DA, Guiver M, Borrow R, Bindra R, Demirjian A, Brown KE, Ladhani SN, Ramsay ME, Bradley DT, Gjini A, Roy K, Chand M, Zambon M, Watson CH. Paediatric acute hepatitis of unknown aetiology: a national investigation and adenoviraemia case-control study in the UK. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:786-796. [PMID: 37774733 DOI: 10.1016/s2352-4642(23)00215-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND An increase in acute severe hepatitis of unknown aetiology in previously healthy children in the UK in March, 2022, triggered global case-finding. We aimed to describe UK epidemiological investigations of cases and their possible causes. METHODS We actively surveilled unexplained paediatric acute hepatitis (transaminase >500 international units per litre) in children younger than 16 years presenting since Jan 1, 2022, through notifications from paediatricians, microbiologists, and paediatric liver units; we collected demographic, clinical, and exposure information. Then, we did a case-control study to investigate the association between adenoviraemia and other viruses and case-status using multivariable Firth penalised logistic regression. Cases aged 1-10 years and tested for adenovirus were included and compared with controls (ie, children admitted to hospital with an acute non-hepatitis illness who had residual blood samples collected between Jan 1 and May 28, 2022, and without known laboratory-confirmed diagnosis or previous adenovirus testing). Controls were frequency-matched on sex, age band, sample months, and nation or supra-region with randomised selection. We explored temporal associations between frequency of circulating viruses identified through routine laboratory pathogen surveillance and occurrence of cases by linear regression. SARS-CoV-2 seropositivity of cases was examined against residual serum from age-matched clinical comparison groups. FINDINGS Between Jan 1 and July 4, 2022, 274 cases were identified (median age 3 years [IQR 2-5]). 131 (48%) participants were male, 142 (52%) were female, and one (<1%) participant had sex data unknown. Jaundice (195 [83%] of 235) and gastrointestinal symptoms (202 [91%] of 222) were common. 15 (5%) children required liver transplantation and none died. Adenovirus was detected in 172 (68%) of 252 participants tested, regardless of sample type; 137 (63%) of 218 samples were positive for adenovirus in the blood. For cases that were successfully genotyped, 58 (81%) of 72 had Ad41F, and 57 were identified as positive via blood samples (six of these were among participants who had undergone a transplant). In the case-control analysis, adenoviraemia was associated with hepatitis case-status (adjusted OR 37·4 [95% CI 15·5-90·3]). Increases in the detection of adenovirus from faecal samples, but not other infectious agents, in routine laboratory pathogen surveillance correlated with hepatitis cases 4 weeks later, which independently suggested an association (β 0·06 [95% CI 0·02-0·11]). No association was identified for SARS-CoV-2 antibody seropositivity. INTERPRETATION We observed an association between adenovirus 41F viraemia and paediatric acute hepatitis. These results can inform diagnostic testing recommendations, clinical management, and exploratory in vitro or clinical studies of paediatric acute hepatitis of unknown aetiology. The role of potential co-factors, including other viruses and host susceptibility, requires further investigation. FUNDING None.
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Affiliation(s)
| | | | | | | | | | | | | | - David Leeman
- UK Health Security Agency, London, UK; UK Field Epidemiology Training Programme, UK Health Security Agency, London, UK
| | | | | | | | | | - Frances Rowley
- UK Field Epidemiology Training Programme, UK Health Security Agency, Cardiff, UK; Public Health Wales, Cardiff, UK
| | | | | | | | | | - Helen Callaby
- UK Health Security Agency, London, UK; Medical Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Erik Renz
- UK Health Security Agency, London, UK
| | | | | | | | | | - Emma A Davies
- Manchester Medical Microbiology Partnership, Manchester Royal Infirmary, Manchester, UK
| | - Shazaad Ahmad
- Public Health Scotland, Glasgow, UK; Manchester Medical Microbiology Partnership, Manchester Royal Infirmary, Manchester, UK
| | - Nicholas Machin
- Manchester Medical Microbiology Partnership, Manchester Royal Infirmary, Manchester, UK
| | | | | | | | | | | | - Kathy Li
- Belfast Health and Social Care Trust, Belfast, UK
| | | | - Ines Ushiro-Lumb
- UK Health Security Agency, London, UK; NHS Blood and Transplant, London, UK
| | | | | | - Jane Hartley
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Chayarani Kelgeri
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | | | - Deirdre A Kelly
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Malcolm Guiver
- Manchester Medical Microbiology Partnership, Manchester Royal Infirmary, Manchester, UK
| | - Ray Borrow
- UK Health Security Agency, London, UK; Manchester Medical Microbiology Partnership, Manchester Royal Infirmary, Manchester, UK
| | | | - Alicia Demirjian
- UK Health Security Agency, London, UK; Evelina Children's Hospital, London, UK; King's College London, London, UK
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7
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Terebuh P, Olaker VR, Kendall EK, Kaelber DC, Xu R, Davis PB. Liver abnormalities following SARS-CoV-2 infection in children under 10 years of age. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.21.23295905. [PMID: 37790424 PMCID: PMC10543044 DOI: 10.1101/2023.09.21.23295905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Objective Beginning in October 2021 in the US and elsewhere, cases of severe pediatric hepatitis of unknown etiology were identified in young children. While the adenovirus and adenovirus-associated virus have emerged as leading etiologic suspects, we attempted to investigate a potential role for SARS-CoV-2 in the development of subsequent liver abnormalities. Design We conducted a study utilizing retrospective cohorts of de-identified, aggregated data from the electronic health records of over 100 million patients contributed by US health care organizations. Results Compared to propensity-score-matched children with other respiratory infections, children aged 1-10 years with COVID-19 had a higher risk of elevated transaminases (Hazard ratio (HR) (95% Confidence interval (CI)) 2.16 (1.74-2.69)) or total bilirubin (HR (CI) 3.02 (1.91-4.78)), or new diagnoses of liver diseases (HR (CI) 1.67 (1.21-2.30)) from one to six months after infection. Patients with pre-existing liver abnormalities, liver abnormalities surrounding acute infection, younger age (1-4 years), or illness requiring hospitalization all had similarly elevated risk. Children who developed liver abnormalities following COVID-19 had more pre-existing conditions than those who developed abnormalities following other infections. Conclusion These results indicate that SARS-CoV-2 may prime the patient for subsequent development of liver infections or non-infectious liver diseases. While rare (~1 in 1,000), SARS-CoV-2 is a risk for subsequent abnormalities in liver function or the diagnosis of diseases of the liver. What is already known on this topic Clusters of severe hepatitis in children in 2022 coincident with the increase in COVID-19 infections in children raised the question of the contribution of SARS-CoV-2 to the hepatitis outbreak, though it was soon determined that SARS-CoV-2 was not the primary etiologic agent. What this study adds SARS-CoV-2 may prime the patient for subsequent development of liver infections or non-infectious liver diseases. How this study might affect research practice or policy Despite the mild initial disease in children, there may be longer term consequences of COVID-19, such as liver abnormalities, that warrants further investigation.
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Affiliation(s)
- Pauline Terebuh
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Veronica R. Olaker
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ellen K. Kendall
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David C. Kaelber
- The Center for Clinical Informatics Research and Education, Departments of Medicine and Pediatrics, The MetroHealth System, Cleveland, Ohio
| | - Rong Xu
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Pamela B. Davis
- Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, Ohio
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8
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Mammas IN, Drysdale SB, Charalampous C, Koletsi P, Papatheodoropoulou A, Koutsaftiki C, Sergentanis T, Merakou K, Kornarou H, Papaioannou G, Kramvis A, Greenough A, Theodoridou M, Spandidos DA. Navigating paediatric virology through the COVID‑19 era (Review). Int J Mol Med 2023; 52:83. [PMID: 37503745 PMCID: PMC10555476 DOI: 10.3892/ijmm.2023.5286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
The present review article presents the key messages of the 8th Workshop on Paediatric Virology organised virtually by the Institute of Paediatric Virology based on the island of Euboea in Greece. The major topics covered during the workshop were the following: i) New advances in antiviral agents and vaccines against cytomegalovirus; ii) hantavirus nephropathy in children; iii) human rhinovirus infections in children requiring paediatric intensive care; iv) complications and management of human adenovirus infections; v) challenges of post‑coronavirus disease 2019 (COVID‑19) syndrome in children and adolescents; and vi) foetal magnetic resonance imaging in viral infections involving the central nervous system. The COVID‑19 era requires a more intensive, strategic, global scientific effort in the clinic and in the laboratory, focusing on the diagnosis, management and prevention of viral infections in neonates and children.
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Affiliation(s)
- Ioannis N. Mammas
- Department of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion
- First Department of Paediatrics, School of Medicine, University of Athens, 11527 Athens
- Paediatric Clinic, Aliveri, 34500 Island of Euboea, Greece
| | - Simon B. Drysdale
- Centre for Neonatal and Paediatric Infection, St. George's, University of London, London SW17 0RE
- Department of Paediatrics, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | | | - Patra Koletsi
- Department of Paediatrics, 'Penteli' Children's Hospital, 15236 Palaia Penteli
- Paediatric Intensive Care Unit (PICU), 'Penteli' Children's Hospital, 15236 Palaia Penteli
| | | | - Chryssie Koutsaftiki
- COVID-19 Reference Centre, 'Rafina' Health Care Centre, 19009 Rafina
- Department of Public Health Policy, School of Public Health, University of West Attica, 11521 Athens
| | - Theodoros Sergentanis
- Department of Public Health Policy, School of Public Health, University of West Attica, 11521 Athens
| | - Kyriakoula Merakou
- Department of Public Health Policy, School of Public Health, University of West Attica, 11521 Athens
| | - Helen Kornarou
- Department of Public Health Policy, School of Public Health, University of West Attica, 11521 Athens
| | - Georgia Papaioannou
- Department of Paediatric Radiology, 'Mitera' Children's Hospital, 15123 Athens, Greece
| | - Anna Kramvis
- Hepatitis Virus Diversity Research Unit, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, 2193 Johannesburg, South Africa
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, King's College London, London SE5 9RS, UK
| | - Maria Theodoridou
- First Department of Paediatrics, School of Medicine, University of Athens, 11527 Athens
| | - Demetrios A. Spandidos
- Department of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion
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9
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Dulek DE. Update on Epidemiology and Outcomes of Infection in Pediatric Organ Transplant Recipients. Infect Dis Clin North Am 2023; 37:561-575. [PMID: 37532391 DOI: 10.1016/j.idc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Pediatric solid organ transplant (SOT) recipients are at risk for infection following transplantation. Data from adult SOT recipients are often used to guide prevention and treatment of infections associated with organ transplantation in children. This article highlights key recent pediatric SOT-specific publications for an array of infectious complications of organ transplantation. Attention is given to areas of need for future study.
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Affiliation(s)
- Daniel E Dulek
- Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
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10
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Peters AL, Kim S, Mourya R, Asai A, Taylor A, Rogers M, Campbell K, Fei L, Miethke A, Balistreri WF, Bezerra JA. Recent Increase in Incidence of Severe Acute Hepatitis of Unknown Etiology in Children is Associated with Infection with Adenovirus and Other Nonhepatotropic Viruses. J Pediatr 2023; 259:113439. [PMID: 37088181 PMCID: PMC10524234 DOI: 10.1016/j.jpeds.2023.113439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/13/2023] [Accepted: 03/19/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To evaluate whether the nature and severity of non-A-E severe acute hepatitis in children noted by the World Health Organization from late 2021 through early 2022 was indeed increased in 2021-2022 compared with prior years. STUDY DESIGN We performed a single-center, retrospective study to track the etiology and outcomes of children with non-A-E severe acute hepatitis in 2021-2022 compared with the prior 3-year periods (2018-2019, 2019-2020, and 2020-2021). We queried electronic medical records of children ≤16 years of age with alanine or aspartate aminotransferase levels of >500 IU. Data were analyzed for the periods of October 1, 2021, to May 1, 2022, and compared with the same time periods in 2018-2021. RESULTS Of 107 children meeting entry criteria, 82 cases occurred from October to May of 2018-2022. The average annual case number was 16.3 in 2018-2021 compared with a 2-fold increase (to 33) in 2021-2022 (P = .0054). Analyses of etiologies showed that this increase was associated with a higher number of children who tested positive for viruses (n = 16) when compared with the average of 3.7 for 2018-2021 (P = .018). Adenovirus (26.1%) and severe acute respiratory syndrome coronavirus-2 (10.3%) were the most frequently detected viruses in 2021-2022. Despite evidence of acute liver failure in 37.8% of children in the entire cohort and in 47% of those with viral infection, the overall survival rate was high at 91.4% and 88.9%, respectively. CONCLUSIONS The number of children with severe acute hepatitis in our center increased from 2021 to May 2022, with a greater frequency of cases associated with adenovirus, yet transplant-free survival remains high.
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Affiliation(s)
- Anna L Peters
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Seung Kim
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Reena Mourya
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Akihiro Asai
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Amy Taylor
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael Rogers
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kathleen Campbell
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lin Fei
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Alexander Miethke
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH
| | - William F Balistreri
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jorge A Bezerra
- Children's Medical Center at Dallas and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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11
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Mitchell MM, Leng Y, Boppana S, Britt WJ, Gutierrez Sanchez LH, Elledge SJ. Signatures of AAV-2 immunity are enriched in children with severe acute hepatitis of unknown etiology. Sci Transl Med 2023; 15:eadh9917. [PMID: 37494473 PMCID: PMC10501808 DOI: 10.1126/scitranslmed.adh9917] [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: 03/27/2023] [Accepted: 06/21/2023] [Indexed: 07/28/2023]
Abstract
Severe acute hepatitis of unknown etiology in children is under investigation in 35 countries. Although several potential etiologic agents have been investigated, a clear cause for the liver damage observed in these cases remains to be identified. Using VirScan, a high-throughput antibody profiling technology, we probed the antibody repertoires of nine cases of severe acute hepatitis of unknown etiology treated at Children's of Alabama and compared their antibody responses with 38 pediatric and 470 adult controls. We report increased adeno-associated dependoparvovirus A (AAV-A) breadth in cases relative to controls and adeno-associated virus 2 (AAV-2) peptide responses that were conserved in seven of nine cases but rarely observed in pediatric and adult controls. These findings suggest that AAV-2 is a likely etiologic agent of severe acute hepatitis of unknown etiology.
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Affiliation(s)
- Moriah M. Mitchell
- Division of Genetics, Department of Medicine, Howard Hughes Medical Institute, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
- Program in Systems, Synthetic, and Quantitative Biology, Harvard University, Boston, MA 02115, USA
| | - Yumei Leng
- Division of Genetics, Department of Medicine, Howard Hughes Medical Institute, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
| | - Suresh Boppana
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William J. Britt
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz Helena Gutierrez Sanchez
- Division of Gastroenterology, Hepatitis, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stephen J. Elledge
- Division of Genetics, Department of Medicine, Howard Hughes Medical Institute, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
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12
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Otake S, Ikenoue C, Sudani N, Kobayashi M, Takahashi K, Shimada T, Yoshimi I, Saito T, Sunagawa T. National Surveillance of Pediatric Acute Hepatitis of Unknown Etiology, Japan, October 2021-December 2022. Emerg Infect Dis 2023; 29:1288-1291. [PMID: 37209697 DOI: 10.3201/eid2906.221579] [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: 05/22/2023] Open
Abstract
Pediatric acute hepatitis of unknown etiology has been reported globally since April 2022. In Japan, 139 possible cases with onset dates after October 2021 were reported as of December 2022. Three patients required liver transplants, but none died. Rates of adenovirus positivity (11/125, 9%) were lower than those for other countries.
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13
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Servellita V, Sotomayor Gonzalez A, Lamson DM, Foresythe A, Huh HJ, Bazinet AL, Bergman NH, Bull RL, Garcia KY, Goodrich JS, Lovett SP, Parker K, Radune D, Hatada A, Pan CY, Rizzo K, Bertumen JB, Morales C, Oluniyi PE, Nguyen J, Tan J, Stryke D, Jaber R, Leslie MT, Lyons Z, Hedman HD, Parashar U, Sullivan M, Wroblewski K, Oberste MS, Tate JE, Baker JM, Sugerman D, Potts C, Lu X, Chhabra P, Ingram LA, Shiau H, Britt W, Gutierrez Sanchez LH, Ciric C, Rostad CA, Vinjé J, Kirking HL, Wadford DA, Raborn RT, St George K, Chiu CY. Adeno-associated virus type 2 in US children with acute severe hepatitis. Nature 2023; 617:574-580. [PMID: 36996871 PMCID: PMC10170441 DOI: 10.1038/s41586-023-05949-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 03/10/2023] [Indexed: 04/01/2023]
Abstract
As of August 2022, clusters of acute severe hepatitis of unknown aetiology in children have been reported from 35 countries, including the USA1,2. Previous studies have found human adenoviruses (HAdVs) in the blood from patients in Europe and the USA3-7, although it is unclear whether this virus is causative. Here we used PCR testing, viral enrichment-based sequencing and agnostic metagenomic sequencing to analyse samples from 16 HAdV-positive cases from 1 October 2021 to 22 May 2022, in parallel with 113 controls. In blood from 14 cases, adeno-associated virus type 2 (AAV2) sequences were detected in 93% (13 of 14), compared to 4 (3.5%) of 113 controls (P < 0.001) and to 0 of 30 patients with hepatitis of defined aetiology (P < 0.001). In controls, HAdV type 41 was detected in blood from 9 (39.1%) of the 23 patients with acute gastroenteritis (without hepatitis), including 8 of 9 patients with positive stool HAdV testing, but co-infection with AAV2 was observed in only 3 (13.0%) of these 23 patients versus 93% of cases (P < 0.001). Co-infections by Epstein-Barr virus, human herpesvirus 6 and/or enterovirus A71 were also detected in 12 (85.7%) of 14 cases, with higher herpesvirus detection in cases versus controls (P < 0.001). Our findings suggest that the severity of the disease is related to co-infections involving AAV2 and one or more helper viruses.
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Affiliation(s)
- Venice Servellita
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Daryl M Lamson
- Wadsworth Center, New York State Department of Health, David Axelrod Institute, Albany, NY, USA
| | - Abiodun Foresythe
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Hee Jae Huh
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Adam L Bazinet
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Nicholas H Bergman
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Robert L Bull
- Federal Bureau of Investigation Laboratory Division/Scientific Response and Analysis Unit, Quantico, VA, USA
| | - Karla Y Garcia
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Jennifer S Goodrich
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Sean P Lovett
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Kisha Parker
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Diana Radune
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - April Hatada
- California Department of Public Health, Richmond, CA, USA
| | - Chao-Yang Pan
- California Department of Public Health, Richmond, CA, USA
| | - Kyle Rizzo
- California Department of Public Health, Richmond, CA, USA
| | - J Bradford Bertumen
- California Department of Public Health, Richmond, CA, USA
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | | | - Paul E Oluniyi
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jenny Nguyen
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica Tan
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Doug Stryke
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rayah Jaber
- Florida Department of Health, Tallahassee, FL, USA
| | | | - Zin Lyons
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Hayden D Hedman
- Centers for Disease Control and Prevention, Atlanta, CA, USA
- South Dakota Department of Health, Pierre, SD, USA
| | - Umesh Parashar
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Maureen Sullivan
- Association for Public Health Laboratories, Silver Spring, MD, USA
| | - Kelly Wroblewski
- Association for Public Health Laboratories, Silver Spring, MD, USA
| | | | | | - Julia M Baker
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - David Sugerman
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Caelin Potts
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Xiaoyan Lu
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Preeti Chhabra
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | | | - Henry Shiau
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - William Britt
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Caroline Ciric
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Christina A Rostad
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jan Vinjé
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | | | | | - R Taylor Raborn
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Kirsten St George
- Wadsworth Center, New York State Department of Health, David Axelrod Institute, Albany, NY, USA
- Department of Biomedical Science, University at Albany, SUNY, Albany, NY, USA
| | - Charles Y Chiu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, San Francisco, CA, USA.
- Chan-Zuckerberg Biohub, San Francisco, CA, USA.
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14
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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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15
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Tollefson AE, Hussein IT, Toth K, Bowlin TL. Filociclovir is a potent inhibitor of human adenovirus F41. Antiviral Res 2022; 208:105431. [DOI: 10.1016/j.antiviral.2022.105431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/27/2022] [Accepted: 10/04/2022] [Indexed: 11/30/2022]
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16
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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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17
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Alexander EC, Deep A. Characterization of a Hepatitis Outbreak in Children, 2021 to 2022. JAMA Netw Open 2022; 5:e2237091. [PMID: 36255724 PMCID: PMC9579900 DOI: 10.1001/jamanetworkopen.2022.37091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/31/2022] [Indexed: 12/19/2022] Open
Abstract
Importance After a cluster of pediatric cases of hepatitis of unknown etiology were identified in Scotland in March 2022, the World Health Organization published an outbreak alert, and more than 1010 probable cases were reported. Some cases progressed to acute liver failure and required liver transplant. Although many patients had positive results for adenovirus on polymerase chain reaction testing from whole blood samples and/or reported recent COVID-19 infection (with or without seropositivity), the precise pathogenesis remains unclear despite the high potential morbidity of this condition. Objective To summarize the currently available evidence regarding novel pediatric hepatitis of unknown etiology (or novel hepatitis), encompassing case numbers, testing, management, and outcomes. Evidence Review A rapid review of the literature from April 1, 2021, to August 30, 2022, aimed to identify all available published case series and case-control studies of novel hepatitis. The search included PubMed and references and citations of short-listed studies. Findings A total of 22 available case series and case-control studies describing 1643 cases were identified, with 120 children (7.3%) receiving liver transplants and 24 deaths (1.5%). Outcome reporting and testing for adenovirus and SARS-CoV-2 was incomplete. Assessment of disease severity and management was mixed and results regarding testing for adenovirus and SARS-CoV-2 were inconsistent for both serological testing and testing of explant or biopsy liver samples. More recent studies suggest a more plausible role for adenovirus and/or adeno-associated virus 2. Conclusions and Relevance This systematic review without meta-analysis describes the challenge posed by hepatitis of unknown etiology in terms of investigation and management, with many cases progressing to acute liver failure. The lack of clarity regarding pathogenesis means that these children may be missing the potential for targeted therapies to improve outcomes and avert the need for transplant. Clinicians, immunologists, and epidemiologists must collaborate to investigate the pathogenesis of this novel hepatitis.
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Affiliation(s)
- Emma C. Alexander
- Paediatric Intensive Care Unit, King’s College Hospital NHS (National Health Service) Foundation Trust, London, United Kingdom
| | - Akash Deep
- Paediatric Intensive Care Unit, King’s College Hospital NHS (National Health Service) Foundation Trust, London, United Kingdom
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Coilly A, Samuel D. Paediatric acute liver failure: Confirm the outbreak, find the cause and explore the mechanisms. United European Gastroenterol J 2022; 10:789-790. [PMID: 36094884 PMCID: PMC9557952 DOI: 10.1002/ueg2.12306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Audrey Coilly
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,University Paris-Saclay, UMR-S 1193, Villejuif, France.,Inserm, Unité 1193, Villejuif, France.,Hepatinov, Villejuif, France
| | - Didier Samuel
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,University Paris-Saclay, UMR-S 1193, Villejuif, France.,Inserm, Unité 1193, Villejuif, France.,Hepatinov, Villejuif, France
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Ledford H. Mysterious child hepatitis continues to vex researchers. Nature 2022; 607:20-21. [PMID: 35750922 DOI: 10.1038/d41586-022-01706-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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