European Journal of Pediatrics

, Volume 178, Issue 1, pp 61–67 | Cite as

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

  • Sumit Kumar Singh
  • Vibhor Borkar
  • Anshu Srivastava
  • Amrita Mathias
  • Surender Kumar Yachha
  • Ujjal Poddar
Original Article


Various atypical manifestations have been described in acute viral hepatitis (AVH). We evaluated the prevalence, clinical features, response to treatment and outcome of various atypical manifestations of AVH in children. Consecutive children (≤ 18 years) with AVH due to hepatitis A, B, or E were studied while patients with acute or acute on chronic liver failure were excluded. Diagnosis of atypical manifestations was based on standard criteria. A total of 477 children with AVH (median age 7.0 (5–11) years, 74% boys) were seen; 22% (n = 106) had atypical manifestations. Prolonged cholestasis was the most common (11%), followed by ascites (7%), intravascular hemolysis (3%), relapsing hepatitis (2%), acute pancreatitis (1.3%), and thrombocytopenia (0.7%). Atypical manifestations were more common in HAV as compared to HBV (30% vs. 3%, p = 0.00) and HEV (30% vs. 15%, p = 0.07). Prolonged cholestasis was significantly more common in older children (20% in > 10 years vs. 9% in 6–10 years ; p = 0.009 and 5% in 0–5 years of age [p < 0.000]). Ascites was more common in younger children, although not significant. All patients recovered with supportive treatment.

Conclusions: Twenty-two percent of children with AVH have atypical manifestations, more often with HAV infection, and prolonged cholestasis is most common. Recognition of these manifestations ensures correct diagnosis and treatment.

What is Known:

Acute viral hepatitis is a major public health problem in developing countries.

There is limited information about atypical manifestations which may lead to unnecessary investigations, delayed diagnosis and morbidity.

What is New:

Atypical manifestations are common in children, seen most often with HAV infection, and prolonged cholestasis is most common.

Prompt recognition of these manifestations helps in early diagnosis, appropriate management, and preventing unnecessary investigations.

Ensure follow-up until complete recovery and not to miss underlying chronic liver disease.


Atypical manifestations Acute hepatitis Cholestasis Relapsing Children 



Acute on chronic liver disease


Acute on chronic liver failure


Acute kidney injury


Acute liver failure


Alanine aminotransferase


Acute pancreatitis


Aspartate aminotransferase


Acute viral hepatitis


chronic liver disease


Culture negative neutrocytic ascites


Glucose-6-phosphatase dehydrogenase


Hepatitis A virus


Hepatitis B virus


Hepatitis E virus


Intravascular hemolysis


Monomicrobial non-neutrocytic bacterascites


Spontaneous bacterial peritonitis


Ursodeoxycholic acid


Authors’ contributions

SKS collected and analyzed the data drafted the manuscript. VB collected and analyzed the data and drafted the manuscript. AS designed and supervised the study, analyzed the data, and co-drafted the manuscript. AM collected and analyzed the data and co-drafted the manuscript. SKY designed the study and revised the manuscript for important intellectual content. UP analyzed the data and revised the manuscript for important intellectual content. All authors have read and approved the final version to be published.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Informed consent

For this type of study, formal consent is not required.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Sumit Kumar Singh
    • 1
  • Vibhor Borkar
    • 1
  • Anshu Srivastava
    • 1
  • Amrita Mathias
    • 1
  • Surender Kumar Yachha
    • 1
  • Ujjal Poddar
    • 1
  1. 1.Department of Pediatric GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia

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