Hepatitis A, cardiomyopathy, aplastic anemia, and acute liver failure: A devastating scenario

Abstract

Hepatitis A virus (HAV) causes an acute infection and is usually asymptomatic in children. When clinical manifestations appear, these include choluria, jaundice, and abdominal pain. Although infrequent, extra-hepatic manifestations related to HAV have been described, affecting the heart, bone marrow, blood vessels, and other tissues.A 10-year-old boy from a rural area presented with a 15-day history of malaise, fever, and jaundice; laboratory examinations were compatible with HAV infection. The patient turned encephalopathic and was remitted to our center, where laboratory examinations showed a medullary aplasia and fulminant hepatitis requiring a liver transplant that was performed 72 hours after admission. At 24 hours post transplant, the patient developed a cardiomyopathy secondary to HAV, and intravenous immunoglobulin was administered. The patient is still alive and attending his medical check-ups.Although rare, extra-hepatic manifestations of HAV infection have been described in 14% of cases. The groups of patients affected are usually aged and present with high bilirubin levels. Acquired aplastic anemia and myocarditis caused by HAV are uncommon, and its pathophysiology has not yet been elucidated.HAV infection is usually asymptomatic in children, although extra-hepatic manifestations can appear requiring early detection and management.

A Very Rare Complication of Hepatitis A Infection: Acute Myocarditis—A Case Report with Literature Review

“…Precise level of troponin elevation was not provided [ 7 ]. In the third case, reported by Botero et al [ 8 ], their patient had milder elevations of transaminases, but had a more severe coagulopathy with an INR >10, higher elevations of bilirubin, and required liver transplantation. Their patient's cardiomyopathy was milder with an ejection fraction of 59%.…”

“…Their patient's cardiomyopathy was milder with an ejection fraction of 59%. No troponin level was mentioned [ 8 ]. Based on these comparisons, higher elevations in transaminases may be associated with more severe cardiomyopathy.…”

“…Extrahepatic manifestations may include urticarial and maculopapular rash, acute kidney injury, autoimmune hemolytic anemia, aplastic anemia, acute pancreatitis, mononeuritis, reactive arthritis, Guillain–Barre syndrome and pleural or pericardial effusion, glomerulonephritis, polyarteritis nodosa, cryoglobulinemia, and thrombocytopenia [ 4 , 5 ]. Myocarditis is a very rare extrahepatic complication with only three reported cases [ 6 – 8 ].…”

Transient sinus bradycardia caused by hepatitis A virus: a case report

“…Allen et al presented the first case of HAV-induced myocarditis in the USA in 2018 [7]. Botero et al presented a postoperative HAVinduced cardiomyopathy case who developed acute liver failure due to HAV and underwent liver transplantation [8]. Soleimani et al demonstrated the first association of HAV-induced hypotension and bradycardia in an adolescent patient [9].…”

Accelerating Effects of Vitamin E Supplementation on Liver Enzyme Normalization in Children with Acute Hepatitis A Infection; a Single-Blinded Clinical Trial

“…Despite its high affinity for living cells, HAV represents no cytopathic effects against them, and extra-hepatic manifestations of HAV infection are unusual. Nevertheless, there are reports of detrimental effects on the cardiovascular system, bone marrow, kidney, as well as biliary and pancreatic systems (9)(10)(11)(12).…”