Covid-19 Associated Hepatitis in children (CACH) during the second wave of SARS-CoV-2 infections in Central India: Is it a complication or transient phenomenon.

Abstract

Background: Besides Covid-19, SARS-CoV-2 infection has been associated with Multiple Inflammatory Syndrome in children (MIS-C). However, a unique presentation of a transient form of hepatitis in pediatric age group occurring subsequent to the asymptomatic SARS-CoV-2 infection is yet to be reported in children. Presently the clinical work, temporal association and characteristics different than MIS-C of the cases of CAHC is being dealt with. Methods: As a retrospective and follow up observational study we reviewed all pediatric patients presenting with acute hepatitis during the study period from April 2021 to mid- June 2021. We observed a sudden rise of features of hepatitis in a group of pediatric patients during the second wave of SARS CoV-2 infections, where children or adolescents developing sudden onset acute hepatitis with no history of pre-existing liver disease in the absence of familiar etiology of acute hepatitis and with a recent 3-6 week history of RT-PCR positivity or a retrospectively proven Covid-19 infection with high titer SARS CoV-2 antibodies. Such patients had asymptomatic Covid-19 infection, while another very small group (n=8) patients having findings similar to MIS-C was identified with protracted and grave presentation, having multiple organ involvement along with Covid-19 diagnosis. Routine lab workup along with viral serology of acute hepatitis was performed in all such patients. These patients were negative for Hepatitis A, B, C and E but had high titer of SARS CoV-2 antibodies. Results: Among 33 patients who presented with hepatitis, 25 patients showed unique features of CAHC, they had hepatitis only. These patients did not have any typical Covid-19 symptoms, had normal to borderline inflammatory markers, with admission to general care wards, all recovered on supportive treatment without any complications or mortality. Whereas patients with MIS-C (n=8) required admission to critical care, they had high level of inflammatory markers and 3 (37.5%) had an adverse outcome. Conclusion: With emergence of newer variants of concern such as the Delta variant which caused the massive wave of Covid-19 in India, with varied presentations, CAHC is one of them. Such new entities need to be timely identified and differentiated from other types of emerging syndromes in children for appropriate management.