Pediatric acute viral hepatitis with atypical variants: Clinical dilemmas and natural history

Abstract

Classical acute viral hepatitis (AVH) has an uncomplicated outcome. Acute liver failure has a grave prognosis. Atypical manifestations of AVH are a group of disorders that causes significant morbidity and dilemmas in children. These include prolonged cholestasis, relapsing hepatitis, ascitic form of AVH, late-onset hepatic failure (LOHF), intravascular hemolysis, and provoking an autoimmune trigger leading to autoimmune hepatitis. These entities cause significant liver dysfunction or worsening and are often difficult to differentiate from chronic liver disease (CLD). Ascitic form of AVH, LOHF, decompensated CLD and acute-on-chronic liver failure have significant overlapping features that need to be carefully dissected out. In many cases, only on long-term follow-up, these clinical entities can be separately identified. Intravascular hemolysis is usually caused by associated glucose-6-phosphate dehydrogenase deficiency. Rarely CLD such as Wilson disease and autoimmune hepatitis can also present with hemolysis in the initial presentation, which can mimic AVH with hemolysis. Identifying deviations from typical manifestations aid in avoiding unnecessary investigations, allowing focused therapy and alleviating anxiety.

Keywords: Viral, Hepatitis, Atypical, Cholestasis, Relapsing, Hemolysis, Ascites

Core tip: Acute viral hepatitis (AVH) in children can manifest with atypical features in about a quarter of children. The most common entities, such as prolonged cholestasis and relapsing hepatitis, cause liver dysfunction and are often confused with chronic liver diseases (CLDs). Similarly, ascitic form of AVH and late-onset hepatic failure are close differential diagnoses of acute-on-chronic liver failure and decompensated CLD. A combination of a thorough history, clinical findings, basic investigations and outcome on follow-up allows focused workup and management in atypical AVH.