Pediatric Hepatitis C Infection

Abstract

To the Editors: Hepatitis C infection seems to be less common in children than in adults, as reported in studies on supposedly healthy normal populations,1,2 but little is known about the prevalence of hepatitis C in children migrating from areas of the world where the prevalence of the infection is higher. Although hepatitis C infection in childhood is mostly asymptomatic and the histologic progression is slow, recent reports demonstrate the existence of cirrhotic hepatitis C disease in childhood/adolescence.3 We present 2 cases illustrating the need for increased awareness of epidemiologic and clinical aspects of pediatric hepatitis C disease. CASE 1 A 13-year-old girl, while playing with a friend, was injected subcutaneously with a syringe that had previously been used by a person with intravenous drug use. Her local physician initiated prompt testing for possible blood-borne infections 2 days later, revealing positive antibodies to hepatitis C. Subsequent testing for hepatitis C virus (HCV)-RNA by polymerase chain reaction was also positive. Further history revealed that she had been subjected to neonatal exchange transfusion in her native country in South Asia in 1995, and that she was adopted by a Swedish family in the same year. The present family members living in the same house showed negative result for anti-HCV. Further work-up revealed mildly elevated transaminases, hepatitis C genotype 3b and a virus titer of 1.5 million IU/mL. She was later treated with pegylated interferon and ribavirin for 24 weeks with a sustained virologic response. CASE 2 A 15-year-old girl came to Sweden from East Africa in 2009. On arrival, she presented at the emergency ward with fever, fatigue, and had laboratory signs of bone marrow depression and moderately elevated transaminases. Further examination suggested decreased synthetic function of the liver, with serum albumin of 20 g/L (ref., 36–45 g/L) and prothrombin time measured as international normalized ratio of 2.0 (ref., <1.2) and moderate ascites. Diagnostic work-up revealed hepatitis C, genotype 4a, with an HCV-RNA titer of 2.5 million IU/mL. Autoimmune liver disease, Wilson disease, schistosomiasis, tuberculosis, and human immunodeficiency virus were ruled out. The biologic mother was not available for hepatitis C testing. The patient had received some parenteral treatments a few years back. Antiviral treatment to hepatitis C was considered too hazardous, and she is currently awaiting liver transplantation. DISCUSSION The 2 cases illustrate several important aspects of the epidemiology and outcome of pediatric hepatitis C. The first patient was most probably infected when treated with neonatal exchange transfusion and she was rather accidentally diagnosed years later after the needle incident. In 2007, the Swedish National Board of Health and Welfare recommended look-back investigations for hepatitis C infection in patients subjected to parenteral treatment with blood products between 1965 and 1992.4 In the present case 1, with the patient being born after 1992, the current recommendations for screening would have missed her. Although methods for effective screening of blood products were available in Sweden and many other countries as early as 1992, this may not have been the case in some of the countries where foreign adoptees or other children migrating to Sweden originate. Thus, we suggest that look-back screening should include such children who came to Sweden, either as adoptees or for other reasons also after 1992. Patient 2 was brought up in an area of the world with a prevalence of hepatitis C that is higher than in most other parts.5 Screening for the virus in children migrating to Sweden from similar areas is therefore suggested, since less severe cases could be considered for treatment. The exact mode and timing of hepatitis C acquisition by her is unclear. There have been several reports describing pediatric patients with uncompensated cirrhosis due to hepatitis C without any underlying disease and with the subsequent need for liver transplantation.3,6 Unfortunately, the outcome after liver transplantation in such patients is as problematic as in adults.6 Thus, early detection of the infection, with the possibility to offer treatment seems important. Our conclusion from these 2 cases is that additional measures should be taken to detect hepatitis C infection in children belonging to groups with increased risk. This would be relevant regardless of the reason for moving to Sweden, ie, adoption or migration. Björn Fischler, MD, PhD Afrodite Psaros-Einberg, MD Department of Pediatrics CLINTEC, Karolinska Institutet Karolinska University Hospital Huddinge, Stockholm, Sweden