Involvement of the gallbladder in the course of viral hepatitis A in childhood.

The course of acute hepatitis A (AHA) in childhood is most often benign. There are relatively few reports of gallbladder involvement during such infection and its consequences. We discuss the cases of 75 children (mean age = 4.5 years) with confirmed AHA. Clinical and laboratory evaluation upon admission were classical for AHA. Only two children had normal bilirubin levels and 38.7% had visible involvement of the gallbladder with wall thickening of >3 mm, while six met criteria for acute acalculous cholecystitis. There appears to be no clear relationship between thickening of the gallbladder wall and transaminase levels, but a significant relationship with total and direct bilirubin levels (P < 0.05). Ultrasonographic examination should therefore be carried out in each case of AHA and follow-up should be performed with greater caution, if there are changes in the gallbladder wall.

[European outbreak of Hepatitis A in Iceland in 2017. Common radiological changes of the gallbladder].

IAim The incidence of hepatitis A (HAV) in Iceland is low with about one case per year in the last decades. Since 2016, there has been an ongoing outbreak of HAV in men who have sex with men (MSM). The aim of this study was to inves-tigate whether cases diagnosed in Iceland during 2017 had any link to the HAV outbreak in Europe. Methods All cases of HAV in Iceland during 2017 were reviewed retrospectively. Results Four of five cases diagnosed during 2017 were MSM and one was a female. Three cases presented the same week in the summer 2017. The age of the patients was between 25 and 39 years. All the male patients had had sex with men from Europe and/or had travelled to Europe prior to admission. All cases had typical signs and symptoms of HAV infection and in all cases recent infection was confirmed by positive serology and exclusion of other causes of acute hepatitis. Four of five patients had radiological signs of changes in the gallbladder with thickening of the wall and oedema and one underwent later an elective cholecystectomy. Conclusion The outbreak of HAV in MSM Europe reached Iceland in the summer 2017, emphasizing the importance of vaccination in this risk group as recommended by the Icelandic Health Authorities. The review of these cases indicate that changes such as thickening of the gallbladder wall without gallstones in patients with HAV are common. It is important to discrimi-nate patients with these changes associated with HAV from patients with acute acalculus cholecystitis.

Hepatitis A virus genotype IA-infected patient with marked elevation of aspartate aminotransferase levels.

We describe a case of acute liver failure (ALF) without hepatic encephalopathy with marked elevation of aminotransferase due to hepatitis A, according to the revised Japanese criteria of ALF. This liver biopsy of the patient showed compatible to acute viral hepatitis and she immediately recovered without intensive care. She had no comorbid disorders. Of interest, phylogenetic tree analysis using almost complete genomes of hepatitis A virus (HAV) demonstrated that the HAV isolate from her belonged to the HAV subgenotype IA strain and was similar to the HAJFF-Kan12 strain (99% nucleotide identity) or FH1 strain (98% nucleotide identity), which is associated with severe or fulminant hepatitis A. Careful interpretation of the association between HAV genome variations and severity of hepatitis A is needed and the mechanism of the severe hepatitis should be explored.

Usefulness of B-mode and doppler sonography for the diagnosis of severe acute viral hepatitis A.

BACKGROUND: To investigate B-mode and Doppler ultrasonography (US) features correlating with laboratory findings for the diagnosis of severe acute hepatitis (SAH) in patients with hepatitis A virus infection. METHODS: Thirty-nine consecutive serologically proven patients were enrolled. Decreased parenchymal echotexture, periportal tracking, gallbladder wall change, and splenomegaly were assessed on B-mode images. Blood flow velocities were measured in the main portal (V(PORTAL)) and in the hepatic veins, and the hepatic venous pulsatility index was calculated. SAH was defined as high model for end-stage liver disease (MELD) score ≥ 15 with or without coagulopathy. The relationship between US features and laboratory findings was assessed, and SAH diagnosis was evaluated. RESULTS: Serum alanine transaminase and prothrombin time were significantly different depending on the presence of gallbladder wall change and splenomegaly (p < 0.05). V(PORTAL) was inversely correlated with MELD score (r = -0.485) and several laboratory markers. The hepatic venous waveform and hepatic venous pulsatility index were significantly correlated with MELD score. For the diagnosis of SAH, the area under the receiver operating characteristic curve of V(PORTAL) was 0.798. It reached 0.869 in the patients with typical GB change. CONCLUSIONS: Both B-mode and Doppler US correlated well with several laboratory variables and may be helpful to diagnose SAH in patients with hepatitis A virus infection.

Fitz-Hugh-Curtis syndrome: abdominal pain in women of 26 years old.

Fitz-Hugh-Curtis syndrome is an inflammation of the liver capsule as a complication of pelvic inflammatory disease, whose etiologic agent is the most common C. trachomatis. The acute phase Fitz-Hugh-Curtis syndrome may present with pain in upper right quadrant abdomen, commonly confused with other diseases of the hepatobiliary and gastrointestinal tract. Definitive diagnosis is now possible for non-invasive techniques such as ultrasound, computed tomography, as well as techniques for the isolation of the germ responsible available in most centers.

Acute hepatitis A: correlation of CT findings with clinical phase.

BACKGROUND/AIMS: The purpose of this study was to evaluate the incidences of various multi-detector CT (MDCT) findings in acute viral hepatitis A (AHA) and to determine if there are associations between these CT findings and the clinical phases of AHA. METHODOLOGY: Eighty-five patients with AHA were enrolled in this study. The patients were divided into three groups according to changes in their serum alanine aminotransferase and bilirubin levels before and after performing MDCT: group 1 (n = 16, prodromal phase); group 2 (n = 41, jaundice phase); group 3 (n = 28, recovery phase). RESULTS: Small lymph node enlargement in the hepatoduodenal ligament area, perihepatic fat infiltration, gallbladder (GB) changes (wall thickening, contraction, or an undulating inner margin), periportal edema, hepatomegaly, splenomegaly and pelvic fluid collection were noted in 98.8%, 76.5%, 75.3%, 43.5%, 22.4%, 52.9% and 56.5% of the patients, respectively. Fat infiltration, periportal edema, and pelvic fluid collection were most frequent in group 2. GB changes were least frequent in group 1. CONCLUSIONS: At least one of the CT findings suggestive of AHA was noted in 89.4% of the enrolled patients. These CT findings were more frequently identified in patients in the jaundice phase compared to another phases.

Changes in liver stiffness during the course of acute hepatitis A.

BACKGROUNDS/AIMS: In some patients with chronic hepatitis, liver stiffness (LS) findings do not reflect fibrosis stage. This study was performed to evaluate whether acute liver inflammation could influence LS findings. METHODS: Patients with acute hepatitis A admitted to our hospital were included. Hepatitis was classified on admission using serum ALT and bilirubin levels as inflammation phase, jaundice phase, or recovery phase. Patients who admitted during the recovery phase (whose ALT and bilirubin levels fell continuously during hospitalization) and therefore, their peak-ALT and peak bilirubin levels could not be determined were exduded. Enrolled patients underwent FibroScan during hospitalization and after discharge. RESULTS: Seventy-six patients with acute hepatitis A were enrolled (median age, 29 years; 46 men and 30 women). Among them, 33 (43.4%) and 43 (56.6%) patients were admitted during the inflammation phase and jaundice phase, respectively. For patients admitted during the inflammation phase, mean (+/-SD) time from symptom-onset day to maximum ALT level was 7 (+/-3) days. For all patients, mean time from symptom-onset to maximum bilirubin level was 11 (+/-4) days. Mean LS during admission was 8.9 (+/-Pa (median, 8.4 kPa). LS was significantly correlated with serum bilirubin level, which was the only factor found to be significantly associated with the increased LS (>7.08 kPa). In all patients, LS increased gradually from the symptom-onset and peaked at 8-9 days later. CONCLUSIONS: Severe hepatic inflammation can affect the LS findings and thus, care is required when assessing fibrosis stage using LS measurement in patients with severe inflammation.

Prevalencia de enfermedades hepáticas en una población rural de alta montaña: estudio clínico, bioquímico y ecográfico / Prevalence of liver diseases in a small rural community isolated in tne mountain heights: clinical, biochemical and ultrasonographic study

En este estudio clínico, bioquímico y ecográfico se evaluó la prevalencia de hepatopatías en Lara, una comunidad rural aislada de alta montaña en Tucumán, provincia con la máxima prevalencia de infección por HAV en niños de Argentina. Lara carece de agua potable, electricidad y cloacas. Se estudiaron 102 habitantes, lo que representa el 41% de la población. El anti-HBc y anti-HCV fueron negativos en todos los casos. Ningún niño presentó anormalidades hepáticas. El 41% de los adultos refirió ingesta alcohólica y el 12% transfusiones. Se observó incremento leve de ALT en 3 casos (6%). La ecografía demostró esteatosis en 8 individuos (16%), litiasis vesicular en 7 (14%), microcalcificaciones en 5 (10%) y quistes de aspecto parasitario en 4 (8%). La prevalencia de infección por HAV en Lara fue de 89% en adultos y 35% en niños, siendo significativamente menor que la de los niños de la ciudad de Tucumán con nivel socioeconómico medio / alto (53%, p = 0.05) o bajo (74%, p = 0.0006). La diferencia fue más evidente en niños menores de 5 años (0%, 53% y 75% respectivamente). La serología para hidatidosis fue positiva en 3/4 individuos con quistes, 2/5 con microcalcificaciones y 17/85 (20%) con ecografía normal, lo que sugiere que la técnica de Elisa utilizada se asocia a frecuentes resultados falsos positivos. El estudio poblacional de Lara demostró una elevada prevalencia de esteatosis, litiasis vesicular e hidatidosis en adultos, ausencia de infección por HBV y HCV, y una baja exposición al HAV en niños, especialmente en menores de 5 años.(AU)

The goal of this population-based clinical, biochemical and ultrasonographic study was to assess the prevalence of liver diseases in Lara, a small rural community isolated in the mountain heights of Tucumán, a Province of Argentina with the highest reported rates of HAV infection in children. Inhabitants of Lara lack electricity, potable water and a sewer system. The study included 102 individuals representing 41% of the total population. Anti-HBc and anti-HCV were negative in all cases. No children showed clinical, biochemical or ecographic abnormalities. Among adults, 41% referred alcohol consumption and 12% blood transfusions. Only 3 adults (6%) had mildly elevated ALT. Ultrasound showed steatosis in 8 individuals (16%), gallstones in 7 (14%), parenchymal micro-calcifications in 5 (10%) and parasitic cysts in 4 (8%). Prevalence of HAV infection in Lara was 89% in adults and 35% in children, being significantly lower than that of children of medium/high (53%, p=0.05) and low (74%, p=0.0006) socioeconomic level from the city of Tucumán (control groups). These differences were more marked in children aged <5 years (anti-HAV in 0%, 53% y 75% respectively). Serologic tests for echinoccocal disease were positive in 3/4 individuals with parasitic cysts, 2/5 with micro-calcifications and 17/85 (20%) with normal ultrasound, thus suggesting a high rate of false-positive results of the Elisa test utilized. This study showed that in Lara there is a high prevalence of steatosis, gallstones and equinoccocal disease in adults, absenceof HBV and HCV infection and low exposure to HAV in children especially in those aged <5 years. (AU)

[Prevalence of liver diseases in a small rural community isolated in the mountain heights: clinical, biochemical and ultrasonographic study]. / Prevalencia de enfermedades hepáticas en una población rural de alta montaña: estudio clínico, bioquímico y ecográfico.

The goal of this population-based clinical, biochemical and ultrasonographic study was to assess the prevalence of liver diseases in Lara, a small rural community isolated in the mountain heights of Tucumán, a Province of Argentina with the highest reported rates of HAV infection in children. Inhabitants of Lara lack electricity, potable water and a sewer system. The study included 102 individuals representing 41% of the total population. Anti-HBc and anti-HCV were negative in all cases. No children showed clinical, biochemical or ecographic abnormalities. Among adults, 41% referred alcohol consumption and 12% blood transfusions. Only 3 adults (6%) had mildly elevated ALT. Ultrasound showed steatosis in 8 individuals (16%), gallstones in 7 (14%), parenchymal micro-calcifications in 5 (10%) and parasitic cysts in 4 (8%). Prevalence of HAV infection in Lara was 89% in adults and 35% in children, being significantly lower than that of children of medium/high (53%, p = 0.05) and low (74%, p = 0.0006) socioeconomic level from the city of Tucumán (control groups). These differences were more marked in children aged < 5 years (anti-HAV in 0%, 53% and 75% respectively). Serologic tests for echinoccocal disease were positive in 3/4 individuals with parasitic cysts, 2/5 with micro-calcifications and 17/85 (20%) with normal ultrasound, thus suggesting a high rate of false-positive results of the Elisa test utilized. This study showed that in Lara there is a high prevalence of steatosis, gallstones and equinoccocal disease in adults, absence of HBVand HCV infection and low exposure to HAV in children especially in those aged < 5 years.

[Circulating endothelial cells--markers of blood vessel lesions in patients with diffuse liver disease].

The increased level of the circulating endothelial cells (CEC) is in direct dependance with a degree of an endothelial trauma. We defined CEC in blood (cells x 104/L) of 67 adults and children with acute and chronic viral hepatitis (A and B) and healthy volontiars. The author obtained reliable results of increased CEC in all groups consisting of patients with diffuse liver deseases (17,4+/-6,5 and 19,8+/-8,4) in comparison with control groups (3,8+/-1,9 and 3,8+/-1,2) thus CEC can be of practical value as a marker of microvessel lesions of the liver. Endotheliocytemia testifies to be a factor during endothelial trauma in pathogenesis of diffuse liver disease.

Acute disseminated encephalomyelitis associated with hepatitis A virus infection.

We describe the case of a 30-month-old boy who developed acute disseminated encephalomyelitis (ADEM) after hepatitis A virus (HAV) infection and ultimately died. As far as we know, this is only the second case of HAV-associated ADEM to be reported in the literature. The child was brought to hospital with fever, lethargy and weakness of 2 days duration. He had developed jaundice, abdominal pain and malaise 2 weeks beforehand and these problems had resolved within 2 days. Neurological examination revealed lethargy, generalised weakness and positive Babinski's signs bilaterally. Cerebrospinal fluid examination showed mild lymphocytic pleocytosis, increased protein and elevated anti-HAV IgM and IgG titres. Serum HAV IgM and IgG titres were also elevated. Despite aggressive treatment with ceftriaxone, acyclovir and anti-oedema measures, he developed papilloedema and coma within 24 hours of admission. Magnetic resonance imaging of the brain revealed diffuse cerebral oedema and multifocal hyperintensities on T2-weighted images, with most lesions in the white matter of both cerebral hemispheres. The diagnosis of ADEM was established and high-dose steroids and intravenous immunoglobulin were added to the treatment regimen. However, his clinical condition continued to deteriorate and he died on the 20th day in hospital. This case shows that HAV infection can be linked with ADEM. Patients with HAV infection should be examined carefully for central nervous system symptoms during follow-up. Likewise, the possibility of HAV infection should be investigated in cases of ADEM.

Acute pancreatitis with cholestatic hepatitis: an unusual manifestation of hepatitis A.

Acute hepatitis A infection is an uncommon cause of pancreatitis in children. To date, only four cases have been reported in the paediatric literature. We report a 7-year-old girl with acute pancreatitis associated with hepatitis A infection who made a satisfactory recovery. The report highlights the CT findings including focal necrosis not previously reported. Because of the extreme rarity of the complication, the four previous reports have also been single case reports. This paper reviews all these cases with a view to elucidating the aetiopathogenesis of the pancreatitis.

Gallbladder and pancreatic involvement in hepatitis A.

Gallbladder (GB) abnormalities are rarely reported in children, but involvement of the GB has been demonstrated in various inflammatory disorders. Thirty-nine children hospitalized with hepatitis A virus infection were evaluated by ultrasound. Pseudosurgical gallbladder wall of 10 mm or more with striation was found in 10. Pathological echographic findings were found in the pancreas of three patients, one with frank pancreatitis. Ascitic fluid was noted in eight. Pediatricians and pediatric surgeons alike should be familiar with this gallbladder and pancreatic involvement, which might avoid unnecessary procedures or surgery.

Intrauterine transmission of hepatitis A virus.

BACKGROUND: Hepatitis A is a common, self-limited disease transmitted by fecal-oral contamination. CASE: A 23-year-old woman, para 2-0-0-2, developed hepatitis A at 20 weeks' gestation. At 27 weeks, ultrasound revealed polyhydramnios and fetal ascites. Hepatitis A immunoglobulin M antibody in fetal blood obtained by funipuncture confirmed acute hepatitis A infection in the fetus. Polyhydramnios and ascites persisted until 35 weeks, when the fetus developed ultrasound signs of meconium peritonitis, and delivery was accomplished uneventfully. Meconium peritonitis was diagnosed in the neonatal period and treated surgically. CONCLUSION: To our knowledge, this is the first report of intrauterine transmission of hepatitis A. The disease presented with fetal ascites and was confirmed by positive fetal blood serology.

[Contribution of digestive system ultrasonography in the assessment of abdominal pain in children]. / Apport de l'échographie digestive dans les mises au point de douleurs abdominales chez l'enfant.

The quality of modern ultrasonography allows to study not only solid abdominal organs but also digestive walls and abdominal lymphnodes, leading to accurate diagnosis in many cases, and decreasing the use of more aggressive radiological procedures (upper GI baryum studies, baryum enema, intravenous pyelography, etc.). In dealing with abdominal pain in children, the plain XRay film of the abdomen and abdominal echography are performed immediately after history taking and physical examination, and are equally important in the work up of these cases.