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Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 284-286  

Uncommon associations of Hepatitis A in children: Acute respiratory distress syndrome and erosive gastritis

Department of Pediatrics, Pediatric Liver Clinic, B.J. Wadia Hospital for Children, Mumbai, Maharashtra, India

Date of Web Publication19-May-2017

Correspondence Address:
Ira Shah
1/B Saguna, 271/B St. Francis Road, Vile Parle (W), Mumbai - 400 056, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-2870.206580

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Hepatitis A is a common cause of acute hepatitis in children and usually has a benign self-limiting course, moreover so in young children. We report two exceptional cases of erosive gastritis and acute respiratory distress syndrome, respectively, as rare associations of hepatitis A in children. Both children were <5 years of age and eventually recovered.

Keywords:  Acute respiratory distress syndrome, erosive gastritis, hepatitis A

How to cite this article:
Parikh S, Shah I, Bhatnagar S. Uncommon associations of Hepatitis A in children: Acute respiratory distress syndrome and erosive gastritis. Med J DY Patil Univ 2017;10:284-6

How to cite this URL:
Parikh S, Shah I, Bhatnagar S. Uncommon associations of Hepatitis A in children: Acute respiratory distress syndrome and erosive gastritis. Med J DY Patil Univ [serial online] 2017 [cited 2022 Sep 25];10:284-6. Available from:

  Introduction Top

Hepatitis A is a feco-orally transmitted infection which is usually self-limiting in nature. In India, it is still a major cause of sporadic acute hepatitis in children,[1] and lately, focal outbreaks in children in India have been observed.[2] Children with hepatitis A virus (HAV) tend to present with nonspecific gastrointestinal symptoms and jaundice, commonly associated with cholestasis. Within the pediatric age group, it has been found that older children present with HAV infection with more atypical manifestations and complications.[3],[4] However, these two case reports describe young children with serologically determined HAV infection and atypical associations of acute respiratory distress syndrome (ARDS) and erosive gastritis, respectively.

  Case Reports Top

Case 1

A 4½-year-old girl presented with decreased appetite for 15 days, hematemesis 2 days ago, and fever for 1 day. There was no bleeding from any other site. Her diet and milestones were normal. On examination, her heart and milestones were normal. On examination, her heart rate was 110/min, respiratory rate was 26/min, and blood pressure was 98/70 mmHg. She had jaundice with hepatomegaly. Other systems were normal. Investigations are depicted in [Table 1]. In spite of hematemesis, her coagulation profile was normal, suggestive of other causes of her bleed. Esophagogastroscopy showed erosive gastritis which may probably be related to decreased appetite and decreased food intake. Patient was treated with ranitidine, lactulose, and ondansetron. Liver enzymes gradually improved and child recovered after 7 days.
Table 1: Investigations of both patients

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Case 2

A 5-year-old boy presented with fever for 8 days, abdominal pain for 4 days, and 4 episodes of vomiting and puffiness of face with breathlessness for 2 days. Child was admitted outside for the same 2 days ago and treated with ceftriaxone, amikacin, fresh frozen plasma, and platelet transfusion but had no response and was referred for further management. On examination, height was 103 cm, weight was 12 kg, heart rate was 140/min, respiratory rate was 58/min, and blood pressure was 94/50 mmHg. He had edema, hepatomegaly, and decreased air entry in the right side of the chest. Other systems were normal. Investigations are depicted in [Table 1]. His chest X-ray showed ground glass appearance in both lung fields and blood gasses showed hypoxia in spite of oxygen (PaO2/FiO2-152). He was thus diagnosed as moderate ARDS and was put on mechanical ventilation with pressure-controlled ventilation and low tidal volume of 6 ml/kg. Fluid overload was avoided by giving fluid restriction in the child. In view of hepatomegaly with marginally elevated bilirubin and ascites with coagulopathy, hepatitis A ELISA was done which was positive. HIV ELISA, hepatitis B surface antigen, hepatitis C ELISA, dengue IgM, and Leptospira IgM and IgG were negative. Blood culture did not grow any organism. Patient required ventilatory support for 40 days and subsequently recovered.

  Discussion Top

HAV infection normally presents as a self-limiting condition with a benign course in children. Complications are usually seen in older children and adults.[3],[4],[5] Complicated hepatitis A infections in children as young as 4½–5 years of age are rare. The well-documented complications of HAV include prolonged intrahepatic cholestasis, acute renal failure, acute pancreatitis, acalculous cholecystitis, pleural effusion, acute reactive arthritis, and hemolysis.[7],[8],[9] The authors were unable to find a documented reference for erosive gastritis as an association of HAV infection which may have been related to decreased appetite and poor intake of food in the child. However, this patient basically presented with hematemesis to the hospital, and it was only on inquiring with the parents did they notice that she also had a poor appetite before this episode of hematemesis. Thus, erosive gastritis as presenting manifestation of hepatitis A was an unusual presentation of HAV. Similar presentation has been noted in patients with dengue who presented with hematemesis, and on endoscopy, hemorrhagic (and/or erosive) gastritis was seen in 67% of the patients.[10]

ARDS with hepatitis A infection is also a rare and poorly documented association. A search of literature revealed only one relevant study. Willner et al. reported that of 256 people positive for HAV in a local outbreak in the United States, one of them died of complications of fulminant hepatic failure in the form of ARDS.[7] The predisposing role of liver disease in ARDS has also been studied.[6] In our case as reported, ARDS was also associated with pleural effusion and ascites. The patient also presented with thrombocytopenia though the child did have typical manifestations of HAV at onset; however, he went on to develop ARDS. All other coinfections were ruled out in the child, and thus one can conclude that HAV was the predisposing factor for ARDS in this child. The child eventually did recover. Other viruses that have been associated with ARDS are parvovirus.[11] It is uncertain whether the lung injury in these viruses is due to direct effect of the virus or due to immunological process.

The cases reported here thus highlight two extremely uncommon associations of hepatitis A in young children living in an endemic area. Both children eventually recovered.

  Conclusion Top

These cases highlight the importance of looking for uncommon manifestations of common diseases in the clinical setup when presented with difficult cases. Young children can also present unusual manifestations of hepatitis A.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Malathi S, Mohanavalli B, Menon T, Srilatha P, Sankaranarayanan VS, Raju BB, et al. Clinical and viral marker pattern of acute sporadic hepatitis in children in Madras, South India. J Trop Pediatr 1998;44:275-8.  Back to cited text no. 1
Chadha MS, Lole KS, Bora MH, Arankalle VA. Outbreaks of hepatitis A among children in western India. Trans R Soc Trop Med Hyg 2009;103:911-6.  Back to cited text no. 2
Kamath SR, Sathiyasekaran M, Raja TE, Sudha L. Profile of viral hepatitis A in Chennai. Indian Pediatr 2009;46:642-3.  Back to cited text no. 3
Samanta T, Das AK, Ganguly S. Profile of hepatitis A infection with atypical manifestations in children. Indian J Gastroenterol 2010;29:31-3.  Back to cited text no. 4
Stránský J, Honzáková E, Vandasová J, Kyncl J. A relapsing and protracted form of viral hepatitis A: Comparison of adults and children. Vnitr Lek 1995;41:525-30.  Back to cited text no. 5
Sandweiss D, Thomson B. The adult respiratory distress syndrome: The predisposing role of liver disease. Ariz Med 1973;30:264-8.  Back to cited text no. 6
Willner IR, Uhl MD, Howard SC, Williams EQ, Riely CA, Waters B. Serious hepatitis A: An analysis of patients hospitalized during an urban epidemic in the United States. Ann Intern Med 1998;128:111-4.  Back to cited text no. 7
Vaidya P, Kadam C. Hepatitis A: An unusual presentation. Indian Pediatr 2003;40:910-1.  Back to cited text no. 8
Kumar M, Kumar V, Tomar R. Hepatitis A with pleural effusion: A rare association. Ann Trop Paediatr 2009;29:317-9.  Back to cited text no. 9
Chiu YC, Wu KL, Kuo CH, Hu TH, Chou YP, Chuah SK, et al. Endoscopic findings and management of dengue patients with upper gastrointestinal bleeding. Am J Trop Med Hyg 2005;73:441-4.  Back to cited text no. 10
Ferraz C, Cunha F, Mota TC, Carvalho JM, Simões JS, Aparicio JM. Acute respiratory distress syndrome in a child with human parvovirus B19 infection. Pediatr Infect Dis J 2005;24:1009-10.  Back to cited text no. 11


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