Hepatitis A (HAV) is a benign self-limiting infection, spread chiefly by faeco-oral transmission and is common in the developing countries. The main complication of HAV infection is fulminant hepatitis, which occurs in less than 1% of cases. Extra-hepatic complications involving other systems, can occur in HAV infection. Pleural effusion also represents a benign complication of acute hepatitis A infection. We describe here a case of co-infection of HAV and Hepatitis E who developed pleural effusion.
Keywords: Coinfection, hepatitis A and E, pleural effusion
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Kumar KJ, Krishna Kumar HC, Manjunath VG, Umesh L. Pleural effusion: A rare complication of co-infection of hepatitis A and hepatitis E. Ann Trop Med Public Health 2012;5:532-3
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Kumar KJ, Krishna Kumar HC, Manjunath VG, Umesh L. Pleural effusion: A rare complication of co-infection of hepatitis A and hepatitis E. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Nov 24];5:532-3. Available from: https://www.atmph.org/text.asp?2012/5/5/532/105156
Hepatitis A (HAV) is a common self-limiting illness, with prevalence rate highest in areas with limited hygiene and sanitation practice.  The important complication of HAV infection is fulminant hepatitis, which occurs in less than 1% of cases.  Extra-hepatic complications due to HAV occurs in 8% of patients.  Pleural effusion is a rare and benign complication of HAV infection. Only few cases have been reported in the literature. ,,,, We report first case of pleural effusion in a child caused by mixed infection with HAV and Hepatitis E.
A 4-year-old female child presented with 20 days history of fever, pain abdomen, and 3 days history of jaundice .She was previously well. On examination, her temperature was 101°F, PR 106/min, respiratory rate 26/min, and BP 100/60 mm Hg. She had icterus, soft hepatomegaly 6 cm, and 2 cm splenomegaly. Respiratory system examination showed decreased breath sounds in the right infrascapular and right infra axillary areas. Other systems were normal. Laboratory studies revealed Hb12 g/dL, WBC 12,000 cells/cm 3 , and platelet counts 2.25 lakhs/cm 3 . Her blood glucose, urea, and creatinine levels were normal. Liver function tests revealed AST 396 U/L, ALT 719 U/L, alkaline phosphatase 900 U/L, total bilirubin 6.70 mg/dL, direct bilirubin 4.24 mg/dL, total protein 5.8 g/dL and albumin 3.3 g/dL. PT and APTT were normal. Chest radiograph showed massive right-sided pleural effusion. Abdominal ultrasound revealed moderate hepatomegaly with normal echo texture and right pleural effusion. Anti-HAV IgM antibodies and anti-HEV IgM antibodies were detected by ELISA (PANBIO, Australia). Hb S Ag and anti-HCV were negative. Her blood culture was sterile and Widal test was negative. Peripheral smear for malarial parasite, Mantoux test, and ELISA for dengue and leptospira were negative . Child was managed conservatively for 5 days and child improved symptomatically. Fifteen days after discharge follow-up chest x-ray and ultrasound and liver function tests were normal.
HAV is a very common infection in the developing countries such as India and children recover without complications. Several extra hepatic complications have been described in children with HAV.  Acute viral HAV has a mild course in childhood but it may cause complications associated with many organs and systems.  The clinical symptoms of acute HAV are indistinguishable from those caused by other forms of viral hepatitis. Particularly in older children, the onset of illness often is quite abrupt and may consist of fever, myalgia, anorexia, malaise, nausea, intermittent dull abdominal pain, vomiting, and headache.  Pleural effusion is a rare complication of acute HAV. Exact pathogenesis of pleural effusion is unknown though immune complexes have been cited as a possible etiological factor. ,, However, Kurt et al. demonstrated HAV directly from pleural fluid by PCR procedure and it means direct effect of virus on pleural membrane.  Pleural effusion accompanying HAV tends to resolve spontaneously. , Coinfection of HAV and E causing pleural effusion has not been reported earlier to the best of our knowledge. In our patient probably HAV and hepatitis E coinfection must have played a synergistic role in causing pleural effusion. Similar case of pleural effusion with HAV and E with Salmonella More Details coinfection has been reported.  HAV and E are transmitted faeco orally and associated with poor sanitation. Anti-HEV antibodies were detected in 34.1% of HAV patients in an Egyptian study.  Coinfection with multiple hepatotrophic viruses was observed in one-quarter of patients with sporadic HAV in childhood in a study from India.  In the developing countries such as India, hepatitis can be caused by various infections such as typhoid, dengue fever, leptospira, and malaria along with hepatitis A. With this case report, we want to emphasize the importance of considering HAV as a differential diagnosis of pleural effusion. It is very important to remember that pleural effusion is an uncommon complication of HAV infection.
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