Risk of hepatitis in children

WHILE many know that Covid-19 symptoms are milder and cause fewer deaths in children compared with adults, few are aware of the rare but severe manifestations associated with this disease in the latter.

For example, a novel Kawasaki-like syndrome – multisystem inflammatory syndrome in children – has been reported since April 2020. This is a post-acute Covid-19 condition where different body parts can become inflamed, including the heart, liver, intestines, kidneys, lungs, blood and blood vessels, skin, eyes, and brain.

We had a previously healthy five-year-old Chinese boy from Sabah who developed severe hepatitis requiring liver transplant surgery following Covid-19 infection. He had fever, jaundice, tummy pain and vomiting. His liver was swollen and inflamed.

Blood investigations showed severe liver failure. Further tests showed evidence of a recent Covid-19 infection with positive PCR (CT value 40) and antibody (both IgM and IgG) tests for SARS-CoV-2. Extensive investigations for other causes of acute hepatitis were all negative.

As his condition was deteriorating rapidly, he was referred to the University Malaya Medical Centre, and was admitted to the Paediatric Intensive Care Unit for further treatment and preparation for potential emergency liver transplantation.

However, he showed no significant improvement and instead deteriorated further with increasing abnormal brain function (encephalopathy), heart dysfunction and kidney failure.

He required respirator support for his breathing, blood dialysis for kidney failure and liver dialysis for liver failure (haemodialysis and plasmapheresis) together with intravenous nutritional support.

When his condition did not improve despite maximum therapy to support his liver function, emergency liver transplant surgery was necessary. His mother was identified as the living liver donor.

The liver transplantation surgery proceeded uneventfully using the left lobe of liver from the boy’s mother. Both the patient and donor made a smooth recovery after the surgery.

This is the first case of severe Covid-19 infection in children associated with severe hepatitis and acute liver injury, leading to liver transplant surgery in Malaysia.

The case highlights that the liver can be severely affected in children infected with Covid-19.

Recently, the World Health Organisation reported a series of severe hepatitis infection in children from around the world, including the Canada, Japan and the United Kingdom. As seen in our patient, some cases were serious enough to require liver transplant surgery.

Adenovirus, a virus seen commonly in children, is also suspected as a cause. However, adenovirus was excluded in our case after we performed a thorough investigation. Neither our case nor those reported worldwide were vaccinated against Covid-19.

Our case highlights the potential severity of Covid-19 infection in children. We therefore urge the Health Ministry to step up efforts to immunise all children aged five and above with Covid-19 vaccines.

We also urge all parents to get their children vaccinated if they are eligible for Covid-19 vaccines.

PROF LEE WAY SEAH

ASSOC PROF NG RUEY TERNG

ASSOC PROF GAN CHIN SENG

PROF SHIREEN ANNE NAH

ASSOC PROF YOONG BOON KOON

Liver Transplant Team,

Universiti Malaya Medical Centre, Kuala Lumpur

and DR ALVIN KHOH

Gleneagles Hospital, Kota Kinabalu