Atypical manifestations of hepatitis A in children.

Sir, We read the article by Samanta et al. [1] on atypical manifestations of acute viral hepatitis A in children. This is not the first time that these atypical manifestations have been reported from India. Large studies [2, 3] of 172 and 149 cases each of sporadic acute viral hepatitis from two different institutions from north India have been published earlier. The study from Chandigarh has shown that 21.5% of sporadic acute viral hepatitis (72% due to HAV) had ascites, one third of them had associated spontaneous bacterial peritonitis and five children with ascites also had pleural effusion [2]. Similarly, prolonged cholestasis and relapsing hepatitis were reported in 20% and 10% with acute hepatitis A (n=70), respectively in the study from Lucknow [3]. Recently in another study from Lucknow [4], we documented that 13% of 139 cases with sporadic acute viral hepatitis had ascites, and children with ascites had significantly low serum proteins, albumin and prolonged prothrombin time as compared to children without ascites. The authors have probably confused complications of acute viral hepatitis with atypical manifestations. Acute liver failure (ALF) is a known complication of AVH and not an atypical manifestation. In fact 28% of their 32 atypical cases are actually complications (ALF) of AVH and should not have been included as atypical manifestations. Further, authors have used an unusual definition of ALF that seems to be contrary to conventional definition [5]. The definition of acute liver failure (ALF) or fulminant hepatic failure (FHF) in children is not same as in adults as it is difficult to assess encephalopathy in children. The more objective criterion is based on coagulopathy. As per the Pediatric Acute Liver Failure study group, ALF is defined as constellation of acute liver injury coupled with either severe coagulopathy (international normalization ratio or INR>2 or prothrombin time >20 sec) or encephalopathy in the setting of moderate coagulopathy (INR>1.5 or prothrombin time >15 sec) [6].