Dados do Trabalho

Título

Severe Acute Hepatitis of Unknown Aetiology in Children: Mysterious Hepatitis or Misdiagnosed Cases?

Objetivos(s)

This report aimed to provide additional insights into the causality, case definition and laboratorial algorithm of the severe acute hepatitis of unknown aetiology in children and teenagers.

Relato do Caso

On May 2022, a suspected case of severe acute hepatitis of unknown aetiology ("DC_052022" patient, 15 yrs, male) was admitted at the HCPM, Rio de Janeiro. Serological and molecular markers of viral hepatitis A, B, C, D, and E; CHIKV, ZIKV, DENV, YF, CMV, and EBV; SARS-CoV-2 and Influenza; Herpes, Rubella and Measles all tested negative. Because of a controversial serology for hepatitis E virus (anti-HEV IgG negative and IgM borderline), a water sample collected at the patient's residence was sent to the virological analysis at Fiocruz. Aiming to refine both virological and environmental investigation, faecal samples from the patient and his family contacts and water samples from the patient´s school were assessed for detecting HAV, HEV, adenovirus, and enterovirus using both RT-qPCR and conventional PCR. None of the four enteric viruses were detected in faecal or environmental samples by RT-qPCR. However, a nested PCR designed for the VP1/2A region of HAV genome detected HAV RNA in a water fountain sample from the patient's school. Strikingly, the faecal samples from the patient and his twin brother had an inconclusive result (nonspecific electrophoretic pattern in agarose gel) by nested PCR. It is important to emphasize that the patient was not vaccinated against Hepatitis A, and by the time of this investigation, a waterborne hepatitis A outbreak was reported in another school from the same city.

Conclusão

Therefore, the possibility of HAV infection (or another enterically transmitted viruses) should not be ruled out in this case of "mysterious hepatitis", considering that stool samples were collected 45 days after the onset of the disease. As the exposure to HAV decreases in young children, adolescents and young adults unvaccinated against hepatitis A will remain vulnerable to HAV into their school years and beyond. The occurrence of hepatitis A outbreaks reinforces the need of vaccination in this risk group.

Agradecimentos

To the HCPM-RJ Pediatric Unit and to the “DC_052022” patient and family.