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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. Lancet Child Adolesc Health 2023; 7:786-796. [PMID: 37774733 DOI: 10.1016/s2352-4642(23)00215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Morfopoulou S, Buddle S, Torres Montaguth OE, Atkinson L, Guerra-Assunção JA, Moradi Marjaneh M, Zennezini Chiozzi R, Storey N, Campos L, Hutchinson JC, Counsell JR, Pollara G, Roy S, Venturini C, Antinao Diaz JF, Siam A, Tappouni LJ, Asgarian Z, Ng J, Hanlon KS, Lennon A, McArdle A, Czap A, Rosenheim J, Andrade C, Anderson G, Lee JCD, Williams R, Williams CA, Tutill H, Bayzid N, Martin Bernal LM, Macpherson H, Montgomery KA, Moore C, Templeton K, Neill C, Holden M, Gunson R, Shepherd SJ, Shah P, Cooray S, Voice M, Steele M, Fink C, Whittaker TE, Santilli G, Gissen P, Kaufer BB, Reich J, Andreani J, Simmonds P, Alrabiah DK, Castellano S, Chikowore P, Odam M, Rampling T, Houlihan C, Hoschler K, Talts T, Celma C, Gonzalez S, Gallagher E, Simmons R, Watson C, Mandal S, Zambon M, Chand M, Hatcher J, De S, Baillie K, Semple MG, Martin J, Ushiro-Lumb I, Noursadeghi M, Deheragoda M, Hadzic N, Grammatikopoulos T, Brown R, Kelgeri C, Thalassinos K, Waddington SN, Jacques TS, Thomson E, Levin M, Brown JR, Breuer J. Genomic investigations of unexplained acute hepatitis in children. Nature 2023; 617:564-573. [PMID: 36996872 PMCID: PMC10170458 DOI: 10.1038/s41586-023-06003-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 03/23/2023] [Indexed: 04/01/2023]
Abstract
Since its first identification in Scotland, over 1,000 cases of unexplained paediatric hepatitis in children have been reported worldwide, including 278 cases in the UK1. Here we report an investigation of 38 cases, 66 age-matched immunocompetent controls and 21 immunocompromised comparator participants, using a combination of genomic, transcriptomic, proteomic and immunohistochemical methods. We detected high levels of adeno-associated virus 2 (AAV2) DNA in the liver, blood, plasma or stool from 27 of 28 cases. We found low levels of adenovirus (HAdV) and human herpesvirus 6B (HHV-6B) in 23 of 31 and 16 of 23, respectively, of the cases tested. By contrast, AAV2 was infrequently detected and at low titre in the blood or the liver from control children with HAdV, even when profoundly immunosuppressed. AAV2, HAdV and HHV-6 phylogeny excluded the emergence of novel strains in cases. Histological analyses of explanted livers showed enrichment for T cells and B lineage cells. Proteomic comparison of liver tissue from cases and healthy controls identified increased expression of HLA class 2, immunoglobulin variable regions and complement proteins. HAdV and AAV2 proteins were not detected in the livers. Instead, we identified AAV2 DNA complexes reflecting both HAdV-mediated and HHV-6B-mediated replication. We hypothesize that high levels of abnormal AAV2 replication products aided by HAdV and, in severe cases, HHV-6B may have triggered immune-mediated hepatic disease in genetically and immunologically predisposed children.
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Affiliation(s)
- Sofia Morfopoulou
- Infection, Immunity and Inflammation Department, Great Ormond Street Institute of Child Health, University College London, London, UK
- Section for Paediatrics, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Sarah Buddle
- Infection, Immunity and Inflammation Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Oscar Enrique Torres Montaguth
- Infection, Immunity and Inflammation Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Laura Atkinson
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - José Afonso Guerra-Assunção
- Infection, Immunity and Inflammation Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mahdi Moradi Marjaneh
- Section for Paediatrics, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
- Section of Virology, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Riccardo Zennezini Chiozzi
- University College London Mass Spectrometry Science Technology Platform, Division of Biosciences, University College London, London, UK
| | - Nathaniel Storey
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Luis Campos
- Histopathology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - J Ciaran Hutchinson
- Histopathology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - John R Counsell
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Gabriele Pollara
- Division of Infection and Immunity, University College London, London, UK
| | - Sunando Roy
- Infection, Immunity and Inflammation Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Cristina Venturini
- Infection, Immunity and Inflammation Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Juan F Antinao Diaz
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Ala'a Siam
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Gene Transfer Technology Group, EGA-Institute for Women's Health, University College London, London, UK
| | - Luke J Tappouni
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Zeinab Asgarian
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Joanne Ng
- Gene Transfer Technology Group, EGA-Institute for Women's Health, University College London, London, UK
| | - Killian S Hanlon
- Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Alexander Lennon
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Andrew McArdle
- Section for Paediatrics, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Agata Czap
- Division of Infection and Immunity, University College London, London, UK
| | - Joshua Rosenheim
- Division of Infection and Immunity, University College London, London, UK
| | - Catarina Andrade
- Histopathology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Glenn Anderson
- Histopathology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jack C D Lee
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rachel Williams
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Charlotte A Williams
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Helena Tutill
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Nadua Bayzid
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Luz Marina Martin Bernal
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Hannah Macpherson
- Department of Neurodegenerative Disease, Queen Square Institute of Neurology, University College London, London, UK
| | - Kylie-Ann Montgomery
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Neurodegenerative Disease, Queen Square Institute of Neurology, University College London, London, UK
| | - Catherine Moore
- Wales Specialist Virology Centre, Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, UK
| | - Kate Templeton
- Department of Medical Microbiology, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Claire Neill
- Public Health Agency Northern Ireland, Belfast, UK
| | - Matt Holden
- School of Medicine, University of St. Andrews, St. Andrews, UK
- Public Health Scotland, Edinburgh, UK
| | - Rory Gunson
- West of Scotland Specialist Virology Centre, Glasgow, UK
| | | | - Priyen Shah
- Section for Paediatrics, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Samantha Cooray
- Section for Paediatrics, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Marie Voice
- Micropathology Ltd, University of Warwick Science Park, Coventry, UK
| | - Michael Steele
- Micropathology Ltd, University of Warwick Science Park, Coventry, UK
| | - Colin Fink
- Micropathology Ltd, University of Warwick Science Park, Coventry, UK
| | - Thomas E Whittaker
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Giorgia Santilli
- Molecular and Cellular Immunology, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Paul Gissen
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Jana Reich
- Institute of Virology, Freie Universität Berlin, Berlin, Germany
| | - Julien Andreani
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Centre Hospitalier Universitaire (CHU) Grenoble-Alpes, Grenoble, France
| | - Peter Simmonds
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dimah K Alrabiah
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
- National Centre for Biotechnology, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Sergi Castellano
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London, UK
- University College London Genomics, University College London, London, UK
| | | | - Miranda Odam
- Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Tommy Rampling
- Division of Infection and Immunity, University College London, London, UK
- UK Health Security Agency, London, UK
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - Catherine Houlihan
- Division of Infection and Immunity, University College London, London, UK
- UK Health Security Agency, London, UK
- Department of Clinical Virology, University College London Hospitals, London, UK
| | | | | | | | | | | | | | | | | | | | | | - James Hatcher
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Surjo De
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Malcolm Gracie Semple
- Pandemic Institute, University of Liverpool, Liverpool, UK
- Respiratory Medicine, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Joanne Martin
- Centre for Genomics and Child Health, The Blizard Institute, Queen Mary University of London, London, UK
| | | | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, UK
| | | | | | | | - Rachel Brown
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chayarani Kelgeri
- Liver Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Konstantinos Thalassinos
- University College London Mass Spectrometry Science Technology Platform, Division of Biosciences, University College London, London, UK
- Institute of Structural and Molecular Biology, Division of Biosciences, University College London, London, UK
- Institute of Structural and Molecular Biology, Birkbeck College, University of London, London, UK
| | - Simon N Waddington
- Gene Transfer Technology Group, EGA-Institute for Women's Health, University College London, London, UK
- Medical Research Council Antiviral Gene Therapy Research Unit, Faculty of Health Sciences, University of the Witswatersrand, Johannesburg, South Africa
| | - Thomas S Jacques
- Histopathology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Developmental Biology and Cancer Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Emma Thomson
- Medical Research Council-University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Michael Levin
- Section for Paediatrics, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Julianne R Brown
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Judith Breuer
- Infection, Immunity and Inflammation Department, Great Ormond Street Institute of Child Health, University College London, London, UK.
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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