Original Research Article Journal of Gandaki Medical College-Nepal

Evaluation of clinical spectrum of Hepatitis A in

ABSTRACT

Introduction: Hepatitis A is one of the causes of morbidity and mortality in children in developing countries like Nepal.
Hepatitis A virus is a positive-strand RNA virus that is transmitted feco-orally through person-to-person contact. Lack
of awareness, overcrowding, and poor sanitation have led to increased infection mainly in many rural areas. This study
was conducted to assess the clinical course of hepatitis A, blood parameters and its associated complications in patients
admitted pediatric ward. Methods: A hospital-based cross-sectional study was conducted on pediatric patients who
had presented with icterus. Only serologically confirmed cases by the detection of IgM antibodies against Hepatitis A
virus (HAV) ELISA were included in the study group. The clinical course and lab profiles of the patients were analyzed.
Results: A total of 75 patients were positive for HAV IgM A (serology) and were included in the study. The majority of
children seen were in the age group of 5 to 12 years (51%). The most common symptoms were icterus. More than a five-
fold rise in AST and ALT (SGPT) was seen in 58 cases (77.3%) and 62 cases (82.6%) respectively. More than 2,000 U/L of
AST and ALT were seen in 10 cases (13.3%) and 14 cases (18.6%) respectively. Conclusions: It was found that vomiting,
abdominal pain and icterus were most common clinical features. Elevated prothrombin time and raised liver enzymes
were most common lab findings. The most common abdominal ultrasound finding was ascites. No patients presented
with severe complications.
Keywords: Children, complications, Hepatitis A.

INTRODUCTION
*Correspondence:
Dr. Nabraj Subedi Hepatitis A virus (HAV) is a positive-strand RNA virus that is
Department of Pediatrics transmitted feco-orally through person-to-person contact. Poor
sanitation, overcrowding, or food and water contamination are
Gandaki Medical College Teaching Hospital &
the causes of its outbreaks.1 Hepatitis A is a widespread disease,
Research Center, Pokhara, Nepal
accounting for 1.4 million cases annually worldwide.2-4 The unusual
Email: nrsped@gmail.com clinical manifestations include cholestatic, relapsing, and fulminant
ORCID iD: https:/orchid.org/0000-0001- hepatitis.5 In developing countries, infection is acquired early in life,
6219-7505 mostly anicterically about 90% of exposure occurs by the age of five
and universal exposure by adolescence.6
Submitted: February 7, 2024
Accepted: May 20, 2024 Clinical manifestations can vary from mild, anicteric illness to
fulminant hepatitis.7 Acute liver failure occurs in less than 1%
To cite: Subedi N, Shrestha B, Bhattarai A, of cases. Extra-hepatic complications of hepatitis A are unusual.2
Paudel S, KC N. Evaluation of clinical spectrum Although it is usually self-limiting, it can still cause considerable
of Hepatitis A in children admitted at a morbidity and mortality.8,9 There is a paucity of data related to the
clinical course of hepatitis A in children in Nepal.
tertiary care center in Western Nepal. JGMC
Nepal. 2024;17(1):59-62. This study was done to assess clinical course of hepatitis A, blood
DOI: 10.3126/jgmcn.v17i1.60036 parameters and its associated complications in pediatric patients at
Gandaki Medical College in Pokhara, Nepal.
METHODS
A hospital based cross-sectional study was conducted at Department
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JGMC-N | Volume 17| Issue 01 | January-June 2024
Clinical Spectrum of Hepatitis A in children Original Research Article

of pediatrics, Gandaki Medical College Teaching Hospital and vomiting 49(64.5%). Other symptoms were fever
and Research Center, Pokhara. Data collection was done 47(61.8%), and abdominal pain 47(61.8%). Hepatomegaly
from September 5, 2021 to September 4, 2022 .The was present in 19(25%) of the cases. Splenomegaly was
ethical clearance was obtained from the Institutional seen in 8(10.5%) patients. Few enlarged mesenteric lymph
Review committee of Gandaki Medical College (Ref. No. nodes were seen in five cases. Nephrolithiasis with focal
21/2078/2079). Written consent was taken from the hydronephrosis was seen in one patient. Deviation of the
patient’s parents. Children aged between 2 to 15 years, face towards the right side was seen in 1(1.3%) patient and
who had presented with icterus/ duration of jaundice less rashes over the whole body were seen in 1(1.3%) patient.
than 3 months were enrolled in the study. Only serologically The longest duration of hospital stay was seven days in one
confirmed cases by the detection of IgM antibodies against patient. Thrombocytopenia was seen in four cases (5.3%).
HAV (ELISA) were included in the study group.
The findings of liver function tests (LFT) are depicted in
Patients above 15 years of age, patients with jaundice of Table 1. Coagulopathy in the form of excessive prolongation
duration more than three months, negative serological test, of PT was seen in 30(40%) cases. More than five-fold rise
children with chronic liver disease, and those on hepatotoxic in AST and ALT (SGPT) were seen in 58(77.3%) cases and
drugs were excluded from the study. 62(82.6%) cases respectively. More than 2,000 U/L of AST
and ALT were seen in 10(13.3%) cases and 14(18.6%)
Other viral hepatitis markers (HBsAg, Anti HCV, Anti HEV)
cases respectively. ALP was elevated in 69(92%) cases. The
were taken into account in all cases. Anti-HAV IgM [ELISA],
ultrasound findings are given in table 2. Most common USG
Hemoglobin (Hb), total leucocyte count (TLC), differential
findings were ascities 40(53.33%) and thickening of wall
leucocyte count (DLC), platelet count, serum bilirubin,
of gall bladder 35(46.66%).
Alaninetransaminase (ALT), Aspartate transaminase
(AST), Alkaline phosphatase (ALP), serum albumin, serum Table 1: Liver function tests findings in Hepatitis A
globulin, total proteins, Prothrombin time (PT), Activated children(N= 75)
partial thromboplastin time (APTT), blood urea, serum Parameters(LFT) Cases(N=75) Percentage(%)
creatinine, blood sugar, serum amylase and ultrasonography Serum bilirubin>1mg/dl 75 100%
of the abdomen and thorax were the other investigations Elevated AST(>40 U/L) 73 97.33%
Elevated ALT(>40 U/L) 72 96%
performed. Any complication associated with Hepatitis A in
Elevated ALP 69 94.66%
the study population was noted. Abnormal PT(INR>1.5) 30 40%
Serum protein( <6g/dl) 7 9.33%
Using nmaster 2.0 software, sample size was calculated to
Serum albumin(<3.5 g/dL) 10 13.33%
be 95, considering the prevalence of ascites (p=44.9%)10 Serum globulin(<2.5 g/dL) 6 8%
and absolute precision taken as 10%. The sample size in the
Table 2: Ultrasound findings tests findings in the Hepatitis
study was considered to be 75 because out of 83 patients
A children (N=75)
admitted, only 75 were positive for HAV IgM A (serology).
There was a reduced number of patients due to the COVID Findings Number Percentage

outbreak during the study period so the sample size was Ascites 40 53.33%
Pleural effusion 12 16%
reduced.
Gall bladder wall thickening 35 46.66%
The data was entered in a Microsoft excel sheet. It was Reduced ecogenicity of liver 17 22.66%
Increased ecogenicity of liver 11 14.66%
then transferred into SPSS (statistical package for social
sciences) version 25.0 for statistical analysis. Descriptive DISCUSSION
statistics were computed and expressed in percentage and HAV is a small, non-enveloped RNA virus belonging to the
mean. Picornaviridae. Transmission is usually through the fecal
RESULTS and/or oral route by person-to-person contact.9 Unusual
clinical manifestations of hepatitis A include cholestatic,
A total of 83 patients were admitted with findings of icterus
relapsing, and fulminant hepatitis.5 Hepatitis A infection is
over the study period. 75 of the patients were positive for
an important public health problem in developing countries.
HAV IgM A (serology) and were included in the study. The
Hepatitis A itself presents as completely asymptomatic to
majority of children belonged to the age group of 5 to 12
fulminant hepatic failure in the pediatric age group. Fever
years (51%) and the mean age was 3.7 years. Out of 75
was the most common presenting symptom in 92.6% and
patients, 41(53.9%) were males.
diarrhea in 56% of children with HAV. This finding was
The most common symptoms were icterus 57(76%) similar to a few studies which showed fever and diarrhea to
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JGMC-N | Volume 17| Issue 01 | January-June 2024
 Original Research Article Clinical Spectrum of Hepatitis A in children

be the presenting complaints.10-12 Hepatitis A, its altered blood parameters, and its associated
complications can be analyzed and further address its
In this study, comparatively less number of patients were
associated morbidities and mortalities.
admitted due to Hepatitis A than in previous years. The
probable reason could be the improved sanitation among The limitations of this study were that it was a cross-
the population due to the COVID times. No case of COVID co- sectional study, the post-treatment improvement couldn’t
infection with Hepatitis A was present in the patients. One be analyzed, and the sample size of the study was less due
of the patients presented with Bell’s palsy with Hepatitis. to the reduced flow of patients than usual due to the COVID
He was provided with the anti-viral treatment acyclovir outbreak times.
and recovered in five days. The raised level of AST and ALT
CONCLUSIONS
did not determine the severity of the cases of hepatitis A, it
was similar to that of findings of previous studies.10 Jaundice and vomiting were the predominant symptoms
found in this study population with the most common age
There has been improvement in sanitary conditions and
group of 5 to 12 years. The most common complications
hygienic practices, accompanied by the Hepatitis A vaccine
were ascites, gall bladder wall thickening, and reduced
(HepA) vaccination, the incidence rate of hepatitis A is
echogenicity of the liver. Hepatitis A immunization
decreasing and the average age at infection is increasing
programs play a crucial role in reducing incidences of
worldwide.13 HepA was first used worldwide in 1992
Hepatitis A infections and its associated complications.
and its role in hepatitis A control has been proven in
Therefore, it is recommended to provide immunization
many countries.14 HepA was first licensed in 1992. Both
to children above one year against Hepatitis A with two
inactivated HepA (HepA-I) and live attenuated HepA
dosages in six months intervals.
(HepA-L) are highly immunogenic.
ACKNOWLEDGEMENT
Immunization with Hepatitis A virus vaccine among
children has shown to reduce the potential for the The authors would like to acknowledge the Department of
manifestations of severe complications. Previous studies Pediatrics and the patients for the successful completion of
have shown that Hepatitis A incidence was seen to decline the study.
92% with universal vaccination of young children in United CONFLICTS OF INTEREST: None declared
States.14 Nearly 100% of people develop protective levels
SOURCE OF FUNDING: None
of antibodies to the virus within one month after a single
dose of the vaccine. Even though a single dose of the AUTHORS' CONTRIBUTIONS
vaccine has protective effects; still, two doses of vaccine are
NS did conceptualization, project administration, formal
recommended to ensure a longer-term protection of about
analysis, investigation, methodology, original draft
five to eight years after vaccination.15
preparation, reviewing & editing the manuscript, BS did
Immune protection post-vaccination can persist for at the investigation, methodology, reviewing & editing of
least 20 years. HepA is effective for both pre-exposure and the manuscript, AB did the investigation, methodology,
post-exposure prophylaxis, especially among children and reviewing & editing the manuscript, SP did the formal
young adults. The incidence of hepatitis A has decreased analysis, resources, visualization, review & editing the
greatly in many countries in the last 30 years, but hepatitis manuscript and NK did formal analysis, resources, review
A outbreaks frequently occur among high-risk populations & editing the manuscript
and those who have not been covered by universal child
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