Atypical presentations of hepatitis A infection in children

  • Sayma Rahman Munmun Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
  • Archana Shrestha Yadav Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
  • Mohammad Benzamin BSMMU
  • Abu Sayed Mohammad Bazlul Karim Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
  • Mohammad Rukunuzzaman Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
  • Mohammad Wahiduzzaman Mazumder Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
  • Suborna Rani Das Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
Keywords: hepatitis A; ascites; prolonged cholestasis; hepatic encephalopathy; atypical

Abstract

Background Hepatitis A is the most common cause of acute viral hepatitis, with a typical simple, self-limiting course. But it is not free from complications. Atypical presentations, such as in the form of prolonged cholestasis, ascites, pleural effusion, relapsing hepatitis, or fulminant hepatic failure, pose challenges to disease management. Knowledge about varying presentations and identification of factors associated with atypical presentations will help to early diagnosis of atypical courses of disease.

Objective To describe various atypical clinical presentations, biochemical findings of hepatitis A infection, and possible related factors.

Methods Ninety-five children aged 1 to 18 years, diagnosed with hepatitis A infection, and admitted to the Department of Pediatric Gastroenterology & Nutrition, BSMMU, Dhaka, Bangladesh from January 2015 to May 2018 were studied retrospectively.

Results Atypical presentations were manifested in 19 (20%) out of 95 children with hepatitis A virus (HAV) infection. The mean age of atypical patients [6.32 (SD 3.45) years] was significantly lower than that of typical patients [8.22 (SD 3.58) years] (P=0.0041). The most common atypical manifestation was ascites (11/19), followed by hepatic encephalopathy (9/19), acute liver failure (719), thrombocytopenia (2/19), pleural effusion (2/19), and cholestasis (1; 1.1%). Children with atypical features had significantly higher international normalized ratio (INR) and serum bilirubin, as well as lower hemoglobin level than the typical group. Children of atypical group had significantly higher number of organomegaly and coagulopathy.

Conclusion Ascites, hepatic encephalopathy, acute liver failure, thrombocytopenia, pleural effusion, and prolonged cholestasis were common forms of atypical presentation. Younger age, organomegaly, higher bilirubin level, prolonged PT, and decreased hemoglobin level could be predictive of an atypical presentation of HAV in children.

Author Biography

Mohammad Rukunuzzaman, Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka

 

 

 

References

1. Feinstone SM, Kapikian AZ, Purceli RH. Hepatitis A: detection by immune electron microscopy of a viruslike antigen associated with acute illness. Science 1973;182:1026–8. DOI: 10.1126/science.182.4116.1026.
2. Satsangi S, Dhiman RK. Combating the wrath of viral hepatitis in India. Indian J Med Res. 2016;144:1-5. DOI: 10.4103/0971-5916.193275.
3. Sarker NR, Saha SK, Ghosh DK, Adhikary A, Mridha A, Alam MR. Seropositivity of viral markers in icteric children. Bangladesh Med J. 2014;43:26-9. DOI: 10.3329/bmj.v43i1.21373.
4. Jeong SH, Lee HS. Hepatitis A: clinical manifestations and management. Intervirology. 2010;53:15-9. DOI: 10.1159/000252779.
5. Tong MJ, el-Farra NS, Grew MI. Clinical manifestations of hepatitis A: recent experience in a community teaching hospital. J Infect Dis. 1995;171:15-8. PMID: 7876641.
6. Bell BB, Shapiro CG. Hepatitis A virus. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases, 2nd ed. Pennsylvania: Churchill Livingstone Inc; 2003: 1188 – 92.
7. Rook M, Rosenthal P. Hepatitis A in children. In: Jonas MM, editors.Viral hepatitis in children: unique features and opportunities. Boston: Humana Press; 2010. p. 1-12.
8. Schiff ER. Atypical clinical manifestations of hepatitis A. Vaccine. 1992;10:18-20. DOI: 10.1016/0264-410X(92)90534-Q.
9. Gordon SC, Reddy KR, Schiff L, Schiff ER. Prolonged intrahepatic cholestasis secondary to acute hepatitis A. Ann Intern Med. 1984;101:635-7. DOI: 10.7326/0003-4819-101-5-635.
10. Amarapurkar DN, Amarapurkar AD. Extrahepatic manifestations of viral hepatitis. Ann Hepatol. 2002;1:192-5. PMID: 15280806.
11. Verucchi G, Calza L, Chiodo F. Viral hepatitis A with atypical course. Clinical, biochemical and virological study of 7 cases. Ann Ital Med Int. 1999;14:239-45. PMID: 10638016.
12. Poddar U, Thapa BR, Prasad A, Singh K. Changing spectrum of sporadic acute viral hepatitis in Indian children. J Trop Pediatr. 2002;48:210-3. DOI: 10.1093/tropej/48.4.210.
13. Singh SK, Borkar V, Srivastava A, Mathias A, Yachha SK, Poddar U. Need for recognizing atypical manifestations of childhood sporadic acute viral hepatitis warranting differences in management. Eur J Pediatr. 2019;178:61-7. DOI: 10.1007/s00431-018-3262-3.
14. Fleischer B, Fleischer S, Maier K, Wiedmann KH, Sacher M, Thaler H, Vallbracht A. Clonal analysis of infiltrating T lymphocytes in liver tissue in viral hepatitis A. Immunology. 1990;69:14-9. PMID: 2312151.
15. Gürkan F. Ascites and pleural effusion accompanying hepatitis A infection in a child. Clin Microbiol Infect. 2000;6:286-7. DOI: 10.1046/j.1469-0691.2000.00077-3.x.
16. Erdem E, Urganc? N, Ceylan Y, Kara N, Ozcelik G, Gulec SG. Hepatitis A with pleural effusion, ascites and acalculous cholecystitis. Iran J Pediatr. 2010;20:479-82. PMID: 23056750.
17. Sotelo N, de los Ángeles Durazo M, Gonzalez A, Dhanakotti N. Early treatment with N-acetylcysteine in children with acute liver failure secondary to hepatitis A. Ann Hepatol. 2009;8:353-8. DOI: 10.1016/S1665-2681(19)31749-1.
18. Samanta T, Ganguly S. Aetiology, clinical profile and prognostic indicators of children with acute hepatic failure admitted in a teaching hospital in Kolkata. Trop Gastroenterol. 2007;28:135–9. PMID: 18384007.
19. Dalai R, Malhotra S, Gupta AK, Mandal M, Kant S. A rare case of childhood Hepatitis A infection with pleural effusion, acalculous cholecystitis, and ascites. Journal of family medicine and primary care. 2018 Nov;7(6):1581. DOI: 10.4103/jfmpc.jfmpc_298_18.
20. Bukulmez A, Koken R, Melek H, Dogru O, Ovali F. Pleural effusion: a rare complication of hepatitis A. Indian J Med Microbiol. 2008;26:87-8. DOI: 10.4103/0255-0857.38871.
21. Kamath SR, Sathiyasekaran M, Raja TE, Sudha L. Profile of hepatis A in Chennai. Indian Pediatr. 2009;46:642– 3. PMID: 19638667.
22. Chitambar SD, Fadnis RS, Joshi MS, Habbu A, Bhatia SG. Case report: hepatitis A preceding Guillain–Barré syndrome. J Med Virol. 2006;78:1011–4. DOI: 10.1002/jmv.20656.
23. Cheema SR, Arif F, Charney D, Meisels IS. IgA-dominant glomerulonephritis associated with hepatitis A. Clin Nephrol. 2004;62:138-43. DOI: 10.5414/cnp62138.
24. Tanir G, Aydem?r C, Tuygun N, Yildirim I. Transient sinus bradycardia in a child during the course of acute hepatitis A. Turk J Gastroenterol. 2007;18:195–7. PMID: 17891695.
25. Yoon EL, Yim HJ, Kim SY, Kim JH, Lee JH, Lee YS, et al. Clinical courses after administration of oral corticosteroids in patients with severely cholestatic acute hepatitis A; three cases. Korean J Hepatol. 2010;16:329-33. DOI: 10.3350/kjhep.2010.16.3.329.
26. Cheema HA, Fayyaz Z, Parkash A, Malik HS. Atypical presentations of hepatitis A in children presenting to the Children Hospital Lahore, Pakistan. Infect Dis J Pakistan. 2014;23:709-13. PMID: 30346119.
27. Yilmaz-Çiftdogan D, Köse E, Aslan S, Gayyurhan E. Atypical clinical manifestations of hepatitis A among children aged 1-16 years in South-Eastern Region of Turkey. Turk J Pediatr. 2015;57:339-44. PMID: 30346119.
Published
2021-11-22
How to Cite
1.
Munmun S, Yadav A, Benzamin M, Karim ASM, Rukunuzzaman M, Mazumder M, Das S. Atypical presentations of hepatitis A infection in children. PI [Internet]. 22Nov.2021 [cited 20Jun.2024];61(6):317-. Available from: https://paediatricaindonesiana.org/index.php/paediatrica-indonesiana/article/view/2451
Section
Pediatric Gastrohepatology
Received 2020-07-16
Accepted 2021-11-04
Published 2021-11-22