CME INDIA Case Presentation by Dr. Vaibhav Agnihotri, MBBS DCH, DNB, Paediatrician, Fellowship neonatology, Fellow in allergy asthma and immunology, PGPN Boston USA, PCBD John Hopkins USA.

Extreme Hyperbilirubinemia in a Child with Hepatitis A – A Rare Pediatric Presentation

CME INDIA Case Study

Quick Take Away

• We present a rare and unique case of an 11-year-old male child from Salasar, Rajasthan, who exhibited one of the highest documented levels of serum bilirubin (65 mg/dL) in pediatric literature associated with Hepatitis A infection.
• The case posed significant diagnostic and therapeutic challenges and required a multidisciplinary approach. Prompt recognition, supportive care, and vigilant monitoring led to a successful outcome.

How Presented?

• An 11-year-old male child presented with the following complaints:
  • Severe abdominal pain
  • Repeated non-bilious vomiting, including one episode of blood-tinged vomitus
  • Refusal of oral intake
  • Fatigue and lethargy
  • Headache
  • Glasgow Coma Scale (GCS) score: 13/15

Past History

• There was no significant prior comorbidity. The child had been admitted and managed symptomatically at multiple hospitals before being referred to our tertiary care center.

Examination Findings:

• Icterus: Profound
• Abdomen: Tenderness present; hepatomegaly and splenomegaly noted
• Neurological Status: Mildly altered sensorium (GCS 13/15)

Investigations:

Ultrasound Abdomen: Ascites, hepatomegaly, splenomegaly

Serum Bilirubin: 65 mg/dL (one of the highest reported in a pediatric Hepatitis A case)

Liver Enzymes: Elevated transaminases sgot 5000, sgpt 6500

Viral Markers: Hepatitis A IgM positive

Coagulation Profile & Electrolytes: Monitored closely and remained within compensable ranges

Diagnosis:

• Acute Hepatitis A with severe hyperbilirubinemia

Management:

A multidisciplinary pediatric team initiated intensive supportive management:

•           Intravenous fluids and electrolyte correction

•           Nutritional support

•           Liver protective agents

•           Monitoring of hepatic encephalopathy signs

•           Serial LFTs and coagulation profiles

No plasma exchange or liver transplant was required.

Outcome:

• The child responded positively to the treatment.
• Bilirubin levels gradually declined, and clinical parameters improved.
• The patient was discharged in good health with stable liver function and follow-up scheduled.

Discussion:

• This case underscores the variability in Hepatitis A presentations and highlights that even extreme hyperbilirubinemia can be managed successfully with early diagnosis and supportive care, without the need for invasive interventions.
• It adds to the growing evidence that severe cases in children, though rare, require high clinical suspicion and team-based management.

Conclusion:

• This case represents one of the highest serum bilirubin levels documented in pediatric Hepatitis A and reinforces the importance of timely referral and coordinated care in saving lives.

CME INDIA Learning Points

• This case involves a rare presentation of Hepatitis A with a total serum bilirubin level of 65 mg/dL, which is exceptionally high for a self-limiting viral hepatitis.
• Hepatitis A typically causes mild to moderate jaundice, with bilirubin levels rarely exceeding 20–25 mg/dL in immunocompetent individuals.
• A bilirubin level above 50 mg/dL is uncommon even in severe acute viral hepatitis, and often raises suspicion for other causes like hemolysis, co-infection, or underlying chronic liver disease.
• In this case, the extremely elevated bilirubin occurred without features of hepatic encephalopathy or acute liver failure, further highlighting its atypical nature.
• Such severe hyperbilirubinemia in Hepatitis A is scarcely reported in literature, making this a rare and notable case in clinical hepatology.
• Supportive management led to gradual recovery, reaffirming the usually benign course of Hepatitis A even in cases with extreme biochemical derangement.

CME INDIA Tail-Piece

• Hepatitis A, historically a childhood infection in India, has seen a notable epidemiological shift, now affecting adolescents and adults more frequently. These older age groups are at increased risk of complications, often necessitating hospitalization.
• This transition is largely attributed to improved socioeconomic conditions, sanitation, and access to clean water, which have reduced early childhood exposure to the virus.
• Recent studies have reported a decline in anti-HAV seroprevalence among adolescents and young adults, with rates as low as 55% in Indian children aged 5–15 years. Consequently, hepatitis A now accounts for a greater proportion of acute viral hepatitis cases in individuals over 15 years of age.
• The highest attack rate (4.6%) is observed in the 15–24 years age group, followed by 3.1% in children aged 5–14 years and 1.2% in those under five. Although the attack rate in adults over 25 years is under 1%, the large economically productive age group between 15 and 59 years makes the overall impact on public health and productivity substantial.
• Recurrent outbreaks in India are commonly reported among adolescents and adults, with contaminated food and water identified as primary sources.
• These findings underscore the urgent need for improved food safety and targeted vaccination of high-risk groups, especially food handlers. Recognizing the shifting disease burden, the Indian government has initiated prevention strategies, including vaccination campaigns.

Hepatitis A is still endemic in India, though improving sanitation has shifted its epidemiology from early childhood infections to adolescent and adult presentations.

Infection is usually self-limiting, but adults are more likely to experience symptomatic disease, including jaundice and fatigue.

Diagnosis is confirmed by detecting anti-HAV IgM antibodies, which typically appear early in the symptomatic phase.

Most patients recover completely without antiviral therapy; supportive care and hydration are the mainstay of treatment.

Rare complications include fulminant hepatic failure, especially in older adults or those with pre-existing liver disease.

Hepatitis A is vaccine-preventable, and vaccination is recommended for children, travelers, and individuals with chronic liver disease.

Outbreaks still occur in India, particularly in areas with poor water quality or during monsoon seasons due to fecal contamination.

Hand hygiene, safe drinking water, and improved sanitation remain key to preventing transmission.

Co-infection with Hepatitis E is possible and can worsen outcomes, particularly in pregnant women.

Routine screening for HAV immunity in adults is not commonly done, but may be considered in healthcare or food industry workers.

Acknowledgments:

Author sincerely thanks the medical and nursing team at [Soni Hospital/Jaipur] and the child’s family for their trust and cooperation

References:

1. Murlidharan S, Sangle AL, Engade M, Kale AB. The Clinical Profile of Children With Hepatitis A Infection: An Observational Hospital-Based Study. Cureus. 2022 Aug 23;14(8):e28290. doi: 10.7759/cureus.28290. PMID: 36168369; PMCID: PMC9506446.
2. https://www.cdc.gov/hepatitis/php/npr-2025/index.html
3. Shenoy B, Andani A, Kolhapure S, Agrawal A, Mazumdar J. Endemicity change of hepatitis A infection necessitates vaccination in food handlers: An Indian perspective. Hum Vaccin Immunother. 2022 Dec 31;18(1):1868820. doi: 10.1080/21645515.2020.1868820. Epub 2021 Feb 17. PMID: 33595412; PMCID: PMC8920195.

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