Atypical manifestations of hepatitis A in children

Abstract

Sir,We read the article by Samanta et al. [1] on atypicalmanifestations of acute viral hepatitis A in children. This isnot the first time that these atypical manifestations havebeen reported from India. Large studies [2, 3] of 172 and149 cases each of sporadic acute viral hepatitis from twodifferent institutions from north India have been publishedearlier. The study from Chandigarh has shown that 21.5%of sporadic acute viral hepatitis (72% due to HAV) hadascites, one third of them had associated spontaneousbacterial peritonitis and five children with ascites also hadpleural effusion [2]. Similarly, prolonged cholestasis andrelapsing hepatitis were reported in 20% and 10% with acutehepatitis A (n=70),respectivelyinthestudyfromLucknow[3]. Recently in another study from Lucknow [4], wedocumented that 13% of 139 cases with sporadic acute viralhepatitis had ascites, and children with ascites had signifi-cantly low serum proteins, albumin and prolonged prothrom-bin time as compared to children without ascites.The authors have probably confused complications ofacute viral hepatitis with atypical manifestations. Acuteliver failure (ALF) is a known complication of AVH andnot an atypical manifestation. In fact 28% of their 32atypical cases are actually complications (ALF) of AVHand should not have been included as atypical manifes-tations. Further, authors have used an unusual definition ofALF that seems to be contrary to conventional definition[5]. The definition of acute liver failure (ALF) or fulminanthepatic failure (FHF) in children is not same as in adults asit is difficult to assess encephalopathy in children. The moreobjective criterion is based on coagulopathy. As per thePediatric Acute Liver Failure study group, ALF is definedas constellation of acute liver injury coupled with eithersevere coagulopathy (international normalization ratio orINR>2 or prothrombin time >20 sec) or encephalopathy inthe setting of moderate coagulopathy (INR>1.5 or pro-thrombin time >15 sec) [6].References