Acute benign pleural effusion, a rare presentation of hepatitis A virus: a case report and review of the literature

Abstract

Introduction Hepatitis A virus infections are mostly asymptomatic or mildly symptomatic, and generally this disease has a benign course and resolves spontaneously. However, intrahepatic and rarer extrahepatic manifestations can complicate typical cases of acute hepatitis. Pleural effusion is an extremely rare extrahepatic entity with 20 cases reported in literature. Case presentation We report herein a recent case of both pleural effusion and ascites accompanying hepatitis A infection in a 5-year-old middle eastern child, diagnosed using serological testing and imaging studies, who was treated with supportive management with full resolution after 2 weeks. In addition, we review available literature regarding hepatitis A virus associated with pleural effusion using PubMed and summarize all reported cases in a comprehensive table. Results Literature contains 20 reported cases of serology-confirmed hepatitis A virus presenting with pleural effusion, most in the pediatric population with average age at presentation of 9 years 8 months. The majority of reported patients had right-sided pleural effusion (50%) or bilateral effusion (45%), while only 5% presented with pleural effusion on the left side. Hepatomegaly and ascites occurred concurrently in 80% and 70% respectively. Supportive treatment without invasive procedures (except one chylothorax case) yielded complete recovery in 95% of cases, while only one case progressed to fulminant liver failure followed by death. Conclusion Acute hepatitis A virus rarely presents with pleural effusion, usually following a benign course with spontaneous resolution in most patients. Pleural effusion does not change the prognosis or require any invasive treatment. Thus, further invasive procedures are not recommended and would only complicate this self-resolving benign condition.

Hepatitis A virus infection associated with bilateral pleural effusion, ascites, and acalculous cholecystitis in childhood: a case report

“…The clinical manifestations and severity vary depending on age and are mainly associated with liver inflammation. In children, it is usually asymptomatic and not accompanied by jaundice; 80% of them recover completely in 3 months [ 4 , 5 ].…”

“…Pleural effusion with hepatitis A virus infection was described in 20 case reports; most of them were children [ 4 ]. It has commonly been reported on the right side in patients during the early period of the disease.…”

“…It is a widespread illness, especially in developing countries due to poor hygiene and sanitation practices [ 3 ]. It is infrequently accompanied by extrahepatic manifestations in children, such as acalculous cholecystitis, pancreatitis, pleural effusion, ascites, urticarial and maculopapular rash, and acute kidney injury [ 4 ].…”

Benign polyserositis and acalculous cholecystitis, a rare presentation of acute viral hepatitis A and E co-infection

“…11 Pleural effusion, found in only 0.1–2% of children 1,2 usually undergoes spontaneous resolution. 12,13 The exact pathogenesis of pleural effusion and ascites with acute viral hepatitis is not known; possible mechanisms include: direct pleural viral invasion as suggested by hepatitis virus ribonucleic acid by polymerase chain reaction in the pleural fluid, 12 immune complex deposition in the pleura, reactive inflammation, decrease in plasma oncotic pressure leading to plasma leak, transient portal vein hypertension or lymphatic pressure due to compression by the hepatic sinusoids, small diaphragmatic defects or passage in diaphragmatic lymphatics. 13…”

A Case of Isolated Right Lung Edema and Liver Injury Induced by High Altitude

“…[ 3 ] A decrease in the plasma oncotic pressure as well as a transient increase in the pressure of the portal vein and/or lymphatics due to compression by the hepatic sinusoids in response to hepatic injury may contribute to the reduction of absorption of pleural effusion, which can induce the formation of right lung edema. [ 4 , 5 ] Hepatic injury might have been underestimated as a potential mechanism underlying the formation of right lung edema at high altitudes. Accordingly, physicians should carefully check for hepatic injury in patients with right lung edema induced by exposure to a high altitude.…”