In this article, the author elaborates on unexplained hepatitis infections among youngsters having a history of COVID-19 infection. The article is also backed up by the Lancet and the WHO reports.

While new COVID-19 cases in India remain at manageable levels, clinicians in India, as well as medical specialists worldwide, wrestle with a strange increase in unexplained hepatitis infections among youngsters who have tested positive for COVID-19.

In a recent assessment of 475 children who tested positive for COVID between April and July of 2021, 37 (about 8 per cent) were diagnosed with COVID Acquired Hepatitis (CAH). Despite rare reports from different regions of India over the last two years, this is the first comprehensive analysis to assess the prevalence of the illness in India.

Clinical manifestations 

Symptoms of CAH include nausea, appetite loss, weakness, and moderate fever. Elevated transaminases are detected, despite the lack of inflammation. Absent are all other common causes of hepatitis, such as related viruses. All 37 children healed "uncomplicatedly," indicating that standard therapy for severe hepatitis, including corticosteroids, fluids, fever control, and vitamins, was adequate for the vast majority of them.

In addition to the typical causal viruses, researchers examined the possibility of hepatitis being caused by the Epstein Barr virus, autoimmune diseases, and the chickenpox virus (varicella). However, it seemed that some youngsters tested positive for "irrelevant tests" such as dengue or varicella-zoster. They hypothesized that the hepatitis was caused by an aberrant immunological response.

Researchers opine:

“Significantly elevated levels of covid-antibodies was shared by all children of COVID -antibodies was shared by all children. A chain of events possibly triggered by unrecognized COVID-19 infection could be causing the mysterious cases of severe hepatitis reported in kids around the world".

Global evidence

According to research released on medRxiv before peer review, children infected with COVID-19 have a dramatically elevated chance of developing liver disease.

A retrospective cohort analysis was conducted using a national database of electronic health records for patients (EHRs). According to a report posted on medRxiv, the study population consists of 796,369 children aged 1 to 10 years, including 245,675 children who contracted COVID-19 between March 11, 2020, and March 11, 2022, and 550,694 children who contracted non-COVID other respiratory infections (ORI) during the same period.

Compared to children infected with other respiratory infections, children infected with COVID-19 had a significantly increased risk for elevated AST or ALT (hazard ratio or HR: 2.52, 95 per cent confidence interval or CI: 2.03-3.12) and total bilirubin (hazard ratio or HR: 2.62, 95 per cent confidence interval or CI: 2.03-3.12). (HR: 3.35, 95 per cent CI: 2.16-5.18).

These findings imply that COVID-19 causes both acute and chronic hepatic complications in juvenile patients. The medRxiv article said that more research is required to determine if the post-COVID-19 linked hepatic harm revealed in this study is connected to the present surge in juvenile hepatitis cases of unknown cause.

Lancet report 

In The Lancet Gastroenterology & Hepatology, a different group of researchers suggests that the afflicted youngsters, many of whom are too young to be vaccinated, may have had moderate or undiagnosed asymptomatic COVID-19 infection.

They hypothesize that Scientists hypothesized that in children with adenovirus infection along with intestinal tropism and history of COVID-19 disease, carrying viral pools leads to rising levels of inflammatory proteins causing liver injury.

SARS-CoV-2 has been found in 18% of reported cases in the UK, and 11% of 97 patients in England with accessible data tested positive for SARS-CoV-2 on admission; three further cases tested positive within 8 weeks previous to admission. Ongoing serological testing is anticipated to reveal an increase in the proportion of children with severe acute hepatitis and past or present infection with SARS-CoV-2.

WHO report 

According to the World Health Organization, the clinical syndrome among known instances is acute hepatitis (liver inflammation) accompanied by significantly increased liver enzymes. Several instances reported gastrointestinal symptoms, such as stomach pain, diarrhoea, and vomiting, prior to the onset of severe acute hepatitis, elevated liver enzyme levels (AST or ALT more than 500 IU/L), and jaundice.

The majority of patients did not develop a fever. In none of these cases, common viruses causing acute viral hepatitis (hepatitis viruses A, B, C, D and E) were found. The continuous arrival of newer variants of SARS-COV-2 is often presented with newer entities among different age groups.

The new research highlights that, specifically amongst children with recent exposure to SARS-CoV-2 the timely recognition of such entities as CAH-C should enable the treating physician in prioritizing cases requiring admissions and initiate specific therapies. Thus, preventing adverse outcomes and reducing the excessive burden on healthcare resources warranted during the pandemic.

Disclaimer- The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.