A total of 151 cases had been reported to the registry at the time of Kohli’s
presentation. Cases peaked at around 20 in May and June, with 10 or fewer cases
reported in July, August and September.
Most children were very young, with a median age of 41 months. Just over
half were boys and 40% were Hispanic. At presentation, 80% reported
gastrointestinal symptoms, followed by fever (27%) and respiratory symptoms
(23%). Some 15% were taking medications for chronic conditions, including nearly
3% on immunosuppressant drugs. Fifteen children (10%) had SARS-CoV-2 infection
during the past year, and 20 (13%) had received COVID-19 vaccines.
Diagnostic testing revealed a range of viruses, but none were present in
a majority of the children. Just over 40% tested positive on a respiratory
infection panel, with common cold viruses being most frequent. Furthermore, 22%
tested positive for adenovirus, 13% for Epstein-Barr virus and 4% for
cytomegalovirus. Kohli noted that there was “a lot of overlap with multiple positive viruses in many patients.”
Laboratory values, including ALT, AST and bilirubin, were elevated. Thirty-six
children (24%) had evidence of autoimmune markers.
Sixty-three children (42%) received liver biopsies. Pathology
descriptions emphasised portal and lobular inflammation with infiltration of CD8
T cells, according to Kohli. Three patients developed hemophagocytic lymphohistiocytosis, a build-up of
white blood cells that can be triggered by viral infections. However, none of
the biopsy samples showed a definitive viral cause of hepatitis.
More than a quarter of the
children (27%) required treatment in an intensive care unit. Eight (5%)
underwent liver transplantation. About a third (32%) received steroids, and
this group was more likely to require transplantation. Kohli acknowledged that
some other centres, such as King’s College Hospital in London, have reported a
higher proportion of transplants, but they may be more likely to have severe
cases referred to them.
Three of the children died.
The good news, Kohli said, is that more than 90% survived with their original
liver intact. Most of the recovered children at his centre returned to normal
liver function, he noted, but the registry does not include long-term follow-up
In this large international
dataset of paediatric patients, “the majority did not have a singular
definitive etiology,” Kohli concluded. He added that continued community
surveillance and close co-operation through the registry are critical to further
investigate the indeterminate causes of hepatitis in children. “This is a call
to arms to all of us,” he said.