An unusual association of pleural effusion with acute viral hepatitis A infection

Abstract

Hepatitis A virus infection is a common public health problem in developing countries primarily due to poor hygiene and sanitation. The clinical features of hepatitis A virus are mostly related to the derangement of liver function with occasional extrahepatic complications. Herein, a 2.5-year-old girl presented with abdominal pain and decreased appetite for 4 days, high-colored urine for 3 days, and yellowish discoloration of the eyes for 2 days. On presentation, there was icterus along with hepatomegaly and diminished breath sounds on the right side were noted 1 day after admission. Chest X-ray revealed right sided pleural effusion; however, ultrasonography of chest and abdomen displayed bilateral pleural effusion (right more than left) and minimal ascites with thickened gall bladder wall. Immunoglobulin M anti-hepatitis-A virus serology was positive. The pleural effusion in this child resolved spontaneously in 10 days. We report this case to highlight that hepatitis A infection should be considered in the differential diagnosis of pleural effusion in a patient with features of acute hepatitis. However, other common causes of pleural effusion such as tuberculosis and parapneumonic effusions that may coexist with hepatitis, especially in developing world, need to be excluded.

Hepatitis a Presenting as Bilateral Pleural Effusion in Two Pediatric Patients

“…The pleural effusion is totally self-limiting and does not signify any complication of hepatitis A infection [1][2][3]. All the reported cases had good recovery except one case described by Tesovic et al [7,8].…”

“…Among these, pleural effusion is an extremely rare association. Although the first such case was described early in 1971 by Gross and Gerding [2], the association of pleural effusion with hepatitis A infection has been infrequently reported in the medical literature [3]. We report two such cases of hepatitis A who presented with pleural effusion.…”

“…It is usually benign with a self-limiting clinical course. Although the clinical picture can vary from mild selflimiting jaundice to fulminant acute liver failure, pleural effusion in association with hepatitis A has been scantily reported in the medical literature [3].…”

“…The ascitic fluid may also have been transported to the pleural space via the diaphragmatic lymphatics or through minor diaphragmatic defects. Obstruction of the veins and lymphatics, as well as hypoalbuminemia, may also contribute to serositis [3]. Further, Goyal et al proposed that a decrease in the plasma oncotic, pressure as well as a transient rise of the pressure in the portal vein and/or lymphatics due to compression by the hepatic sinusoids, may be a contributory factor in some cases [1].…”

“…Valla et al reported that clinically detectable ascites was present in association with acute hepatitis only if the hepatic venous pressure gradient was >6 mmHg [5]. In addition, the pleural fluid can be either exudate or transudate [3] and hence, pleural fluid study cannot be used to conclusively link its pathogenesis to hepatitis A. Yachha et al identified a separate entity called ascitic acute viral hepatitis (AAVH) having a younger age at presentation, lesser frequency of prodromal symptoms, more profound hypoalbuminemia and derangement of prothrombin time. They postulated that AAVH occurs due to more severe injury to the liver as compared to non-AAVH and reported that hypoalbuminemia, as well as transient portal hypertension, is the pathogenetic mechanism of this condition.…”