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Key Features

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Essentials of Diagnosis
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  • Gastrointestinal upset (anorexia, vomiting, diarrhea)

  • Jaundice

  • Liver tenderness and enlargement

  • Abnormal liver function tests

  • Local epidemic of hepatitis A infection

  • Positive anti–hepatitis A virus (HAV) IgM antibody

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General Considerations
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  • Epidemic outbreaks are caused by contaminated food or water supplies and by food handlers

  • Sporadic cases usually result from contact with an infected individual

  • Transmitted by the fecal-oral route

  • Transmission through blood products obtained during the viremic phase is a rare event, although it has occurred in a newborn nursery

  • Following an incubation period of 15–40 days, nonspecific symptoms usually precede jaundice by 5–10 days

  • Risk factors

    • May include direct exposure to a previously jaundiced individual or recently arrived individual from a high prevalence country

    • Consumption of seafood

    • Contaminated water or imported fruits or vegetables

    • Attendance in a day care center

    • Recent travel to an area of endemic infection

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Clinical Findings

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Symptoms and Signs
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  • Two-thirds of children are asymptomatic

  • Fever, anorexia, vomiting, headache, and abdominal pain are typical

  • Dark urine precedes jaundice, which peaks in 1–2 weeks and then begins to subside

  • Stools may become light- or clay-colored

  • Tender hepatomegaly and jaundice are typically present

  • Splenomegaly is variable

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Differential Diagnosis
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  • Pancreatitis

  • Infectious mononucleosis

  • Leptospirosis

  • Drug-induced hepatitis

  • Wilson disease

  • Autoimmune hepatitis and infection with other hepatitis viruses

  • Acquired cytomegalovirus disease may also mimic HAV, although lymphadenopathy is usually present in the former

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Diagnosis

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Laboratory Findings
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  • Elevated serum aminotransferases and conjugated and unconjugated bilirubin levels

  • Positive anti-HAV IgM confirms diagnosis, whereas anti-HAV IgG persists after recovery

  • Although unusual, hypoalbuminemia, hypoglycemia, and marked prolongation of prothrombin time (international normalized ratio [INR] > 2.0) are serious prognostic findings

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Diagnostic Procedures
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  • Percutaneous liver biopsy is rarely indicated

  • "Balloon cells" and acidophilic bodies are characteristic histologic findings

  • Liver cell necrosis may be diffuse or focal, with accompanying infiltration of inflammatory cells

  • Some bile duct proliferation may be seen in the perilobular portal areas alongside areas of bile stasis

  • Regenerative liver cells and proliferation of reticuloendothelial cells are present

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Treatment

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  • No specific treatment measures are required

  • Bed rest is reasonable for the child who appears ill

  • Sedatives and corticosteroids should be avoided

  • During the icteric phase, lower-fat foods may diminish gastrointestinal symptoms but do not affect overall outcome

  • Drugs and elective surgery should be avoided

  • Hospitalization is recommended for children with coagulopathy, encephalopathy, or severe vomiting

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Outcome

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Prevention
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  • Isolation of an infected patient during initial phases of illness is indicated

  • However, most patients are noninfectious by the time the disease becomes overt

  • Stool, diapers, and other fecally stained clothing should be handled with care for 1 week after the appearance of jaundice

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