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chuka_lisСлучаи среди детей, в Индии, во время 2й волны ковида примерно 8% от детской выборки госпиталя, возраст больных, в основном - 2-6 лет. Часть острых ковид-ассоциированных гепатитов (КАГ) была сопряжена с мультисистемным воспалительным синдромом (МВС).
Случаям КАГ предшествовала легкая или асимптоматическая инфекция ковидом, что было подтверждено в свое время либо ПЦР, либо серологией. А тем гепатитам, что были связаны с МВС, предшествовали более серьезные случаи ковида, с вовлечением поражения многих органов. И вот, в случае этих детских гепатитов, спустя 3-6 недель после предположительного заражения, были клинические (см. статью) проявления острого гепатита, с характерными повышениями печеночных маркеров, которые были вылечены для группы КАГ (25 случаев), симптоматически, а среди тех детей, что были с МВС (8), и симптоматичным ковидом, выздоровление шло куда хуже, у них были повышенные уровни цитокинов, кроме гепатитной картины, и тд, и они нуждались в реанимации, и треть умерла.
Авторы обращают внимание врачей-педиатров на то, что может быть такое вот "гепатитное" течение ковида у детей.
Among MIS-C cases hepatic injury has been reported in around 60% of cases (11), while on the other hand among adult patients of Covid-19, most studies have reported signs of liver injury to occur in 20-30% of cases, among them it has been linked to disease severity and outcome (12). This Potentiates the observations that age related differences do exist in the hepatitis associated with Covid-19. Effects of liver injury on outcome in children with Covid-19 are yet to be found, in the context of emerging VOC like the delta variant, with a possibility that different phenotypes of liver injury or complications caused by differences in these. This is substantiated by a recent study which documented that two different phenotypes of liver injury were associated with SARS-CoV2 infection in children, where first phenotype seen during Covid-19 and the second one is seen in cases of MIS-C (13). During the ongoing second wave of SARS-CoV-2 infections along-with children presenting with MIS-C, other presentations like respiratory distress, shock, encephalitis like features and sudden rise in cases of hepatitis among children was noticed. This hepatitis features were typically setting in among previously asymptomatic children beyond 2-weeks post Covid-19, noticeably many of them lacking the hallmarks of inflammation seen in MIS-C. Since these unique cases far outnumbered any other presentations of hepatitis seen in children during this period, the study was planned to correctly identify the cases, to differentiate from the other entities, and to find out its temporal relation with COVID-19 infections. To our knowledge, none of the published studies and reports took a detailed account of such incidences of post Covid-19 hepatitis in pediatric or adolescent age group, as in CAH-C which was unique, different from both the liver injury phenotypes described earlier in children and has been observed during the ongoing second wave of SARS-CoV2 infections. Treatment: Children in the CAH-C group (n=25) admitted in general wards were given supportive therapy consisting of anti-emetics, IV fluids, Multivitamins, Zinc without any use of steroids. Those with MIS-C and hepatitis (n=8) were treated as per the ICMR recommended Covid-19 regimen for children and other supportive treatment inclusive of IVIG (n=1) in child with neurologic symptoms, steroids in all, and oxygen administration (n=3) in intensive care settings, without mechanical ventilation. CAH-C cases were more commonly reported in the age group of 6-11 years and with male preponderance. Similar findings were observed in other large cohort studies. The findings to be noted that CAH-C cases are not only asymptomatic Covid-19 course but also mild disease course. None of the CAH-C cases had any underlying morbidity. These cases presented after 2-4 weeks of showing mild symptoms of Covid-19, or remained asymptomatic for the same period following exposure to a lab confirmed case of Covid-19. These cases peaked following 3-4 weeks in relation to the peak of new cases of Covid-19 during the second wave of SARS-CoV-2 infections in central India. These cases noticeably lacked any remarkably high inflammatory markers or systemic derangements observed in other two previously known phenotypes of liver injury associated with Covid-19 but had high levels of serum bilirubin and a more than 10x ULN, elevated transaminases which are unheard of in the previous two types. Prima facie, the biochemical parameters seen in CAH-C do not resemble either those observed in an active Covid-19 disease which generally has a more protracted course, or in cases with documented comorbidities (17) On the contrary, the MIS-C cases with hepatitis presented clinically with fever often >100 ºF, respiratory distress, abdominal pain, loss of appetite, rash, conjunctival hemorrhages, and encephalitis-like features necessitating intensive care facility. These cases typically presented within 2-3 weeks of symptomatology with moderate to severe symptoms of Covid-19. Their laboratory assessment showed significant association with high inflammatory markers, which were often many folds to the UNL, with borderline elevated aminotransferases, slightly altered INR, markedly raised ferritin levels in 7/8 cases, elevated D-Dimer in 6/8 cases and decreased albumin levels in all cases. All had laboratory confirmed RTPCR positive for Covid-19 within 2-3 weeks, and 3/8 had developed anti SARS CoV-2 antibodies.Cases diagnosed as MIS-C hepatitis were administered standard recommended therapy, including anti-viral drugs when needed, steroids in all cases, IVIG in 1 case, oxygen administration in 3 cases, and mechanical ventilation in 1 case. Despite the best of the treatment and efforts, 3 patients succumbed to the disease. 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. Presently the clinical presentation, temporal association and viral parameters of the cases of CAH-C contrasting to MIS-C hepatitis, have been reported Methods: As a retrospective and follow up observational study we reviewed all pediatric patients presenting with acute hepatitis. There were increased numbers cases with features of hepatitis in pediatric group during the second wave of SARS CoV-2 infections, where 25 children or adolescents developing sudden onset of acute hepatitis without prior liver disease or familiar etiology of acute hepatitis. They had history of COVID-19 RT-PCR positivity within 3-6 weeks or a retrospectively proven Covid-19 infection with high titer SARS CoV-2 antibodies. In contrast a group of 8 COVID-19 patients had features of MIS-C with protracted illness and multiple organ involvement. Results: Among 33 paediatric patients presented with hepatitis, 25 patients had features of CAH-C, They had symptoms of hepatitis only without typical Covid-19 presentations. These patients had normal to borderline increase in inflammatory markers with uneventful recovery following supportive treatment. Whereas remaining 8 MIS-C patients with hepatitis had elevated level of inflammatory markers and required admission in critical care with a mortality of 37.5% ( 3/ 8).
Случаям КАГ предшествовала легкая или асимптоматическая инфекция ковидом, что было подтверждено в свое время либо ПЦР, либо серологией. А тем гепатитам, что были связаны с МВС, предшествовали более серьезные случаи ковида, с вовлечением поражения многих органов. И вот, в случае этих детских гепатитов, спустя 3-6 недель после предположительного заражения, были клинические (см. статью) проявления острого гепатита, с характерными повышениями печеночных маркеров, которые были вылечены для группы КАГ (25 случаев), симптоматически, а среди тех детей, что были с МВС (8), и симптоматичным ковидом, выздоровление шло куда хуже, у них были повышенные уровни цитокинов, кроме гепатитной картины, и тд, и они нуждались в реанимации, и треть умерла.
Авторы обращают внимание врачей-педиатров на то, что может быть такое вот "гепатитное" течение ковида у детей.
Among MIS-C cases hepatic injury has been reported in around 60% of cases (11), while on the other hand among adult patients of Covid-19, most studies have reported signs of liver injury to occur in 20-30% of cases, among them it has been linked to disease severity and outcome (12). This Potentiates the observations that age related differences do exist in the hepatitis associated with Covid-19. Effects of liver injury on outcome in children with Covid-19 are yet to be found, in the context of emerging VOC like the delta variant, with a possibility that different phenotypes of liver injury or complications caused by differences in these. This is substantiated by a recent study which documented that two different phenotypes of liver injury were associated with SARS-CoV2 infection in children, where first phenotype seen during Covid-19 and the second one is seen in cases of MIS-C (13). During the ongoing second wave of SARS-CoV-2 infections along-with children presenting with MIS-C, other presentations like respiratory distress, shock, encephalitis like features and sudden rise in cases of hepatitis among children was noticed. This hepatitis features were typically setting in among previously asymptomatic children beyond 2-weeks post Covid-19, noticeably many of them lacking the hallmarks of inflammation seen in MIS-C. Since these unique cases far outnumbered any other presentations of hepatitis seen in children during this period, the study was planned to correctly identify the cases, to differentiate from the other entities, and to find out its temporal relation with COVID-19 infections. To our knowledge, none of the published studies and reports took a detailed account of such incidences of post Covid-19 hepatitis in pediatric or adolescent age group, as in CAH-C which was unique, different from both the liver injury phenotypes described earlier in children and has been observed during the ongoing second wave of SARS-CoV2 infections. Treatment: Children in the CAH-C group (n=25) admitted in general wards were given supportive therapy consisting of anti-emetics, IV fluids, Multivitamins, Zinc without any use of steroids. Those with MIS-C and hepatitis (n=8) were treated as per the ICMR recommended Covid-19 regimen for children and other supportive treatment inclusive of IVIG (n=1) in child with neurologic symptoms, steroids in all, and oxygen administration (n=3) in intensive care settings, without mechanical ventilation. CAH-C cases were more commonly reported in the age group of 6-11 years and with male preponderance. Similar findings were observed in other large cohort studies. The findings to be noted that CAH-C cases are not only asymptomatic Covid-19 course but also mild disease course. None of the CAH-C cases had any underlying morbidity. These cases presented after 2-4 weeks of showing mild symptoms of Covid-19, or remained asymptomatic for the same period following exposure to a lab confirmed case of Covid-19. These cases peaked following 3-4 weeks in relation to the peak of new cases of Covid-19 during the second wave of SARS-CoV-2 infections in central India. These cases noticeably lacked any remarkably high inflammatory markers or systemic derangements observed in other two previously known phenotypes of liver injury associated with Covid-19 but had high levels of serum bilirubin and a more than 10x ULN, elevated transaminases which are unheard of in the previous two types. Prima facie, the biochemical parameters seen in CAH-C do not resemble either those observed in an active Covid-19 disease which generally has a more protracted course, or in cases with documented comorbidities (17) On the contrary, the MIS-C cases with hepatitis presented clinically with fever often >100 ºF, respiratory distress, abdominal pain, loss of appetite, rash, conjunctival hemorrhages, and encephalitis-like features necessitating intensive care facility. These cases typically presented within 2-3 weeks of symptomatology with moderate to severe symptoms of Covid-19. Their laboratory assessment showed significant association with high inflammatory markers, which were often many folds to the UNL, with borderline elevated aminotransferases, slightly altered INR, markedly raised ferritin levels in 7/8 cases, elevated D-Dimer in 6/8 cases and decreased albumin levels in all cases. All had laboratory confirmed RTPCR positive for Covid-19 within 2-3 weeks, and 3/8 had developed anti SARS CoV-2 antibodies.Cases diagnosed as MIS-C hepatitis were administered standard recommended therapy, including anti-viral drugs when needed, steroids in all cases, IVIG in 1 case, oxygen administration in 3 cases, and mechanical ventilation in 1 case. Despite the best of the treatment and efforts, 3 patients succumbed to the disease. 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. Presently the clinical presentation, temporal association and viral parameters of the cases of CAH-C contrasting to MIS-C hepatitis, have been reported Methods: As a retrospective and follow up observational study we reviewed all pediatric patients presenting with acute hepatitis. There were increased numbers cases with features of hepatitis in pediatric group during the second wave of SARS CoV-2 infections, where 25 children or adolescents developing sudden onset of acute hepatitis without prior liver disease or familiar etiology of acute hepatitis. They had history of COVID-19 RT-PCR positivity within 3-6 weeks or a retrospectively proven Covid-19 infection with high titer SARS CoV-2 antibodies. In contrast a group of 8 COVID-19 patients had features of MIS-C with protracted illness and multiple organ involvement. Results: Among 33 paediatric patients presented with hepatitis, 25 patients had features of CAH-C, They had symptoms of hepatitis only without typical Covid-19 presentations. These patients had normal to borderline increase in inflammatory markers with uneventful recovery following supportive treatment. Whereas remaining 8 MIS-C patients with hepatitis had elevated level of inflammatory markers and required admission in critical care with a mortality of 37.5% ( 3/ 8).
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