hepatitis%20-%20viral%20(pediatric)
HEPATITIS - VIRAL (PEDIATRIC)
The majority of acute viral hepatitis infections are asymptomatic or they can cause an anicteric illness that may not be diagnosed as hepatitis.
Hepatitis A generally causes minor illness in childhood with >80% of infections being asymptomatic. Jaundice and intestinal symptoms usually resolve 2-3 weeks after onset. A patient is infectious 1-2 weeks prior to the clinical illness.
Hepatitis B, C, & D may be symptomatic depending on the mode and time of transmission.
Hepatitis A is predominantly transmitted through oral-fecal by person-person direct transmission and contaminated material or food.
Hepatitis B is transmitted perinatal, horizontal spread, percutaneous, sexual, close person-to-person contact.
Majority of hepatitis C infections are identified in children with repeated exposure to blood products.
Hepatitis D is route of transmission is through sexual, percutaneous especially IV drug use.
Hepatitis E is transmitted primarily through contaminated drinking water and oral-fecal transmission.

Introduction

  • The majority of acute viral hepatitis infections are asymptomatic or they can cause an anicteric illness that may not be diagnosed as hepatitis

Pathogenesis

Routes of Transmission of Hepatitis

Hepatitis A: Predominantly oral-fecal through person to person direct transmission & contaminated material or food

Hepatitis B: Perinatal, horizontal spread [infection acquired from living with a chronic hepatitis B virus (HBV) carrier], percutaneous, sexual, close person-to-person contact (eg by open cuts & sores)

Hepatitis C: Blood transfusions, percutaneous [eg intravenous (IV) drug use, sexual, perinatal]

  • Majority of infections are identified in children with repeated exposure to blood products
  • Conditions associated with hepatitis C virus (HCV) infection in pediatric population:
    • Thalassemia
    • Sickle cell disease
    • Hemophilia
    • History of malignancy
    • Hemodialysis
    • Solid organ transplants
    • IV drug use
    • Multiple sexual partners
    • Mother with chronic HCV
    • Household contact with HCV carrier

Hepatitis D: Sexual, percutaneous especially intravenous (IV) drug use

  • Found only in patients with hepatitis B since it requires the hepatitis B outer coat

Hepatitis E: Primarily through contaminated drinking water & oral-fecal transmission

  • Outbreaks often occur during rainy seasons

Signs and Symptoms

Preicteric Phase

  • Nonspecific systemic symptoms (eg myalgia, nausea & vomiting, fatigue, malaise with discomfort in the right upper quadrant of the abdomen)
  • Altered sense of smell or taste, coryza, photophobia, headache, cough, diarrhea, dark urine & serum sickness-like syndrome
  • Hepatomegaly, splenomegaly & lymphadenopathy may be seen on physical exam

Icteric Phase

  • Jaundice is usually noted after onset of fever or upon lysis of fever

Fulminant Hepatitis

  • Development of symptoms of hepatic encephalopathy (eg confusion, drowsiness) within 8 weeks of symptoms or within 2 weeks of onset of jaundice
  • Hypoglycemia, prolonged prothrombin time (PT)

Hepatitis A

  • Generally causes minor illness in childhood with >80% of infections being asymptomatic
    • Adults are more likely to produce clinical symptoms
  • Intestinal symptoms are usually misdiagnosed as gastroenteritis
  • Jaundice & intestinal symptoms usually resolve 2-3 weeks after onset
  • A patient is infectious 1-2 weeks prior to the clinical illness
  • Atypical courses
    • Cholestatic jaundice: jaundice & severe pruritus last >12 weeks
    • Relapsing hepatitis: a 2nd or 3rd recurrence of signs & symptoms occur after initial abatement
  • Children may infect adults who may experience overt disease & higher risk of mortality

Hepatitis B, C & D

  • May be asymptomatic
  • Symptomatic hepatitis B will depend on the mode & time of transmission
    • Perinatal transmission from mother to child is the most common route for infants & is almost always asymptomatic
    • Other routes of transmission are more likely to produce symptomatic disease (30% of cases transmitted by IV drug use are icteric)
    • Asian populations have a high rate of perinatal acquisition leading to high risk for chronicity
    • Westerners usually acquire HBV later in life
  • Most acute & chronic HCV infections are clinically silent

Hepatitis E

  • Accounts for >50% of acute hepatitis cases in Central & Southeast Asia, India, China & Africa
    • The most common cause of symptomatic hepatitis in children in these areas
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