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Acute viral hepatitis types E, A, and B singly and in combination in acute liver failure in children in north India
N K Arora1, S K Nanda, S Gulati
1Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India.
Insights
Enterically transmitted hepatitis viruses, particularly hepatitis A (HAV) and hepatitis E (HEV), are major causes of acute liver failure in Indian children. Mixed HAV and HEV infections pose significant risks, contributing to childhood mortality.
Area of Science:
- Pediatrics
- Hepatology
- Infectious Diseases
Background:
- Acute liver failure (ALF) in children presents a significant health challenge, especially in developing countries.
- Identifying the etiological agents is crucial for understanding disease progression and outcomes.
Purpose of the Study:
- To investigate the causes and outcomes of acute liver failure in children in India.
- To determine the prevalence of viral hepatitis and other etiologies in pediatric ALF.
Main Methods:
- Prospective study of 44 children (2 months to 13 years) with ALF.
- Etiological investigations included viral marker testing (hepatitis A, B, C, E) and screening for other causes like Wilson's disease and drug toxicity.
- Immunoblot assay and HEV-RNA detection were used for confirmation.
Main Results:
- Viral hepatitis was identified in 75% of cases, with hepatitis E virus (HEV) and hepatitis A virus (HAV) being the most common.
- HEV was implicated in 18 children, HAV in 16, hepatitis B in 5, and hepatitis C in 1.
- Enterically transmitted hepatitis viruses (HAV and HEV) accounted for 60% of ALF cases, with mixed HAV-HEV infection being the largest subgroup.
Conclusions:
- Enterically transmitted hepatitis viruses (HAV and HEV) are the primary drivers of pediatric ALF in this Indian cohort.
- Mixed HAV-HEV infections represent a critical etiological subgroup associated with severe outcomes and childhood mortality.
- Public health strategies should focus on preventing endemic HAV and HEV infections in regions with high prevalence.
Abstract:
The aetiological agents responsible for, and the outcome of, acute liver failure were investigated prospectively in 44 children (29 males, 15 females) attending a tertiary health care facility in India. The children were between the ages of 2 months and 13 years. Studies for viral infections and other etiologies could be carried out in 40 patients. Specific aetiological labels were possible in 35 (87.5%) patients. Thirty (75%) had evidence of acute viral hepatitis. Acute hepatitis E virus (HEV) infection was found in a total of 18 children, with hepatitis A (HAV) in 16, hepatitis B in 5, and C in 1. Seven had isolated infection with hepatitis E, five with A, and four with B. Nine had both E and A infection. Superinfection of HEV was observed in a child with Indian childhood cirrhosis (ICC). Acute HEV infection was confirmed by immunoblot assay in all the patients and in eight of these, HEV-RNA was also detected in the serum. HAV was involved in 37.5% of cases with isolated infection in 10% (4 of 40). The aetiological factors associated with acute liver failure, apart from HAV and HEV, were other hepatotropic viruses (22.5%), Wilson's disease (5%), ICC (5%), and hepatotoxic drugs (7.5%). In five patients, no serological evidence of acute viral hepatitis could be found, neither did the metabolic screen yield any result. It was observed that enterically transmitted hepatitis viruses (HAV and HEV) were associated with 60% of acute hepatic failure in children. Mixed infection of HAV and HEV formed the single largest aetiological subgroup. In developing countries, where hepatitis A and E infections are endemic, severe complications can arise in the case of mixed infection. This may contribute to most of the mortality from acute liver failure during childhood.