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

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Abstract

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.

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Abbreviations

ACLD:

Acute on chronic liver disease

ACLF:

Acute on chronic liver failure

AKI:

Acute kidney injury

ALF:

Acute liver failure

ALT:

Alanine aminotransferase

AP:

Acute pancreatitis

AST:

Aspartate aminotransferase

AVH:

Acute viral hepatitis

CLD:

chronic liver disease

CNNA:

Culture negative neutrocytic ascites

G6PD:

Glucose-6-phosphatase dehydrogenase

HAV:

Hepatitis A virus

HBV:

Hepatitis B virus

HEV:

Hepatitis E virus

IVH:

Intravascular hemolysis

MNB:

Monomicrobial non-neutrocytic bacterascites

SBP:

Spontaneous bacterial peritonitis

UDCA:

Ursodeoxycholic acid

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Authors and Affiliations

  1. Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India

    Sumit Kumar Singh, Vibhor Borkar, Anshu Srivastava, Amrita Mathias, Surender Kumar Yachha & Ujjal Poddar

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  1. Sumit Kumar Singh
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  2. Vibhor Borkar
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  3. Anshu Srivastava
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  4. Amrita Mathias
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  5. Surender Kumar Yachha
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  6. Ujjal Poddar
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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.

Corresponding author

Correspondence to Anshu Srivastava.

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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.

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Communicated by Peter de Winter

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Singh, S.K., Borkar, V., Srivastava, A. et al. Need for recognizing atypical manifestations of childhood sporadic acute viral hepatitis warranting differences in management. Eur J Pediatr 178, 61–67 (2019). https://doi.org/10.1007/s00431-018-3262-3

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  • DOI: https://doi.org/10.1007/s00431-018-3262-3

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