What to Know About the Cases of Acute Hepatitis in Children

Following an unusual series of severe hepatitis cases in children, the Centers for Disease Control and Prevention issued a health alert asking healthcare providers to be on the lookout for symptoms and report any suspected cases of hepatitis of unknown cause to their local and state health departments.

About 450 children worldwide have been affected by acute hepatitis, or inflammation of the liver, with the cause being unknown. The United States has seen more than 100 suspected cases. The largest cluster so far has been in Alabama, where nine children under the age of 10 had the rare condition. In total, 11 children have died and 26 have needed a liver transplant.

Dr. Karen Acker, an infectious diseases specialist at NewYork-Presbyterian Komansky Children’s Hospital and assistant professor of Clinical Pediatrics at Weill Cornell Medicine, and Dr. Mercedes Martinez, medical director of the Intestinal Transplant Program at the Center for Liver Disease and Abdominal Organ Transplantation at NewYork-Presbyterian and professor of Pediatrics and Medicine at Columbia University Vagelos College of Physicians and Surgeons, shared with Health Matters what health officials know about the cases of acute hepatitis in children and what symptoms to look for.

What is acute hepatitis?
Dr. Martinez: Any child can be affected by hepatitis, which is an inflammation of the liver caused by the virus or by the body’s immune response to the virus. Acute hepatitis refers to inflammation of the liver that comes about quickly.

Dr. Acker: For the general population, there are multiple potential causes, including infection, medications (commonly Tylenol), alcohol, and autoimmune conditions. Hepatitis is most commonly caused by viruses, and the viruses that we associate with hepatitis most often are hepatitis A, B, and C (hence their names). We also associate hepatitis with Epstein-Barr virus and cytomegalovirus (CMV), both of which cause infectious mononucleosis, or what is known as mono.

What are the symptoms of hepatitis?
Dr. Acker: Symptoms of hepatitis can include abdominal pain, vomiting, diarrhea, yellow skin (jaundice), and yellow eyes. It is still possible to have hepatitis without jaundice, and thus if someone has worsening abdominal pain, vomiting, and diarrhea, hepatitis should be considered.

Dr. Martinez: The severity of the hepatitis is a spectrum that goes from mild asymptomatic cases — diagnosed only when the healthcare providers test the liver enzymes level — to more severe, life-threatening cases of liver failure.

What do we know about the children who have had this condition?
Dr. Acker: The World Health Organization had reported at least 450 cases in children age 1 month to 16 years old. Many had abdominal pain, vomiting, and diarrhea prior to presenting with hepatitis, as manifested by an increased level of liver enzymes or jaundice.

The CDC posted a health advisory about the cases in a large hospital in Alabama between October 2021 and February 2022. Those patients were treated for hepatitis and found to have evidence of adenovirus 41. Adenovirus 41 is a strain of adenovirus that causes vomiting and diarrhea, most commonly in young children. Adenovirus infections are not typically associated with hepatitis in otherwise healthy children, which is a reason why these cases have prompted further investigation. As yet, we still do not know conclusively if all of these cases are linked or caused by adenovirus.

How is hepatitis cured?
Dr. Acker: In most cases, acute hepatitis resolves on its own as the body fights the viral infection. In the most severe cases resulting in liver failure, a liver transplant is required.

The best way to prevent transmission of adenovirus is washing your hands well (lathering with soap for 30 seconds and rinsing under running water) after using the bathroom and before touching your face or eating food.

For children who have severe cases of hepatitis, when is a liver transplant needed?
Dr. Martinez: A liver transplant is indicated when the condition is so severe that the liver function is affected, causing acute liver failure. Acute liver failure is a rare, rapidly progressive loss of liver function that can cause serious complications, including excessive bleeding and increasing pressure in the brain. It’s a medical emergency requiring hospitalization and close monitoring by experts to determine whether a liver transplant is needed. Yellow discoloration of the eye could be the first sign noticed by parents. Once liver failure is diagnosed, patients should be transferred to a transplant center for management.

How concerned should parents be about these cases?
Dr. Acker: These reports should not create increased alarm. Parents should be assured that these clusters of cases do not necessarily indicate that we are seeing more hepatitis than before or that there is necessarily an outbreak of adenovirus. Whenever a cluster of cases that appear to have a common link are identified, further investigation is needed, and these alerts and warnings are meant to ensure that we keep a close eye on new potential cases. Overall, this should be considered a very rare occurrence.

Dr. Martinez: There is no reason to panic. We do not have the full spectrum of the problem at this point. The uptake of the cases could be due to a virus — or a more robust immune system response to the virus — but it could also be due to increased recognition of the cases due to awareness. Parents should be vigilant for signs of hepatitis like yellow discoloration of skin and eye, and physicians should also be aware that this is a rare condition and check liver tests in patients who present with atypical gastrointestinal complaints.