#16,782
We've a follow-up to yesterday's report on the UK's HSA Investigation Into An Unusual Increase In Hepatitis In Children, where we learn that some of these children have become ill enough to have required liver transplants.
Predictably, some on social media are already suggesting (without evidence) the COVID vaccine is to blame for this surge - despite most of these cases have occurred in children under the age of 5 - who are too young to receive the vaccine.
SARS-CoV-2 infection, on the other hand, has been linked to severe liver dysfunctions (see Liver injury in COVID-19: clinical features and treatment management), although primarily among older patients (> 60), those with severe COVID infection, or those with preexisting liver ailments.
There are a lot of other potential causes worth considering, including other non-hepatitis A-E viruses (e.g. Epstein-Barr virus, cytomegalovirus, and herpes simplex), environmental toxins, autoimmune diseases, and ingestion of certain medications.
Late yesterday the UKHSA published the following update - including guidance for physicians - in order to try to sort out the cause.
Guidance
Increase in acute hepatitis cases of unknown aetiology in children
Published 8 April 2022
UKHSA is working with the NHS and public health colleagues across the UK to investigate the potential cause of an unusually high number of acute hepatitis cases being seen in children from England, Scotland and Wales in the past few weeks. There is no known association with travel, and hepatitis viruses (A to E) have not been detected in these children.
The clinical syndrome in identified cases is of severe acute hepatitis with markedly elevated transaminases, often with jaundice, sometimes preceded by gastrointestinal symptoms including vomiting as a prominent feature, in children up to the age of 16 years. In England, there are approximately 60 cases under investigation with most cases being 2 to 5 years old. Some cases have required transfer to specialist children’s liver units and a small number of children have undergone liver transplantation. Based on reports from the specialist units, no child has died. The underlying cause of this increase in presentation since early 2022 currently remains unknown.
Clinicians are asked to be alert to this emerging situation, and to be vigilant to children presenting with signs and symptoms potentially attributable to hepatitis that may require liver function testing. These include:GPs should be alert to children presenting with symptoms compatible with acute hepatitis and seek advice from their local Trust.
- discolouration of urine (dark) and/or faeces (pale)
- jaundice
- pruritis
- arthralgia/myalgia
- pyrexia
- nausea, vomiting or abdominal pain
- lethargy and or loss of appetite
Clinicians are asked to be aware of potential new cases of unexplained acute hepatitis in children aged 16 years or under, with a serum transaminase >500 IU/L (AST or ALT). All staff involved in the care of these children should use standard IPC precautions with optimal placement in a single en-suite room whilst the patient is considered infectious and until resolution of symptoms. Follow protocols that would normally apply in the investigation of acute hepatitis and handling of specimens. There should be a low threshold for seeking expert clinical support from, or specialist referral to one of the three paediatric liver centres (King’s College, Birmingham Women’s and Children’s and Leeds Teaching Hospitals) for children who are clinically unwell or deteriorating.
Cases of acute hepatitis in children up to the age of 16 years with a serum transaminase >500 IU/L, in which hepatitis A to E has been excluded, should be notified to local health protection teams by telephone between 9am and 5pm, including weekends.
The following investigations should be performed locally where available. Referral for specialist testing should be via normal arrangements:
Positive results should be reported following usual process.
In addition, please consider the following additional tests if relevant clinical history: leptospirosis PCR (blood and urine) and serology (blood), throat swab for group A streptococci, serum for anti-streptolysin O titre (ASOT).
Further testing may be required. If possible, the following additional samples should be stored for future testing as soon as an acute case of unexplained hepatitis with serum transaminase >500 IU/L (AST or ALT) in a child aged 16 years or under is identified:Any sample positive for a pathogen should be stored for typing.
- serum and EDTA samples
- nose and throat swabs (bacterial and viral)
- faecal sample for further testing as required
- urine sample for further testing as required
Clinicians wishing to discuss testing for any acute case of unexplained hepatitis with serum transaminase >500 IU/L (AST or ALT) in a child aged 16 years or under should contact the Imported Fever Service on 0844 778 8990.
Please see UKHSA for the latest updates on this emerging incident.
