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Reddi, Y.R., M.D., M.A.M.S., Professor and Head of the Department of Paediatrics, Osmania Medical College, Director of Paediatric Services, Institute of Child Health and Superintendent, Niloufer Hospital, Hyderabad, India. Rohini, K., M.D., D.C.H., Research Scholar, Kusuma, G., M.D., D.C.H., Assistant Professor of Paediatrics and Sudhakar Rao, V., M.D. (Ped.), D.C.H. (Bom.), D.A.B.P. (U.S.A.), F.A.A.P. Assistant Professor of Paediatrics Research.
DISCUSSION
Out of 28339 cases admitted in the children’s ward of Niloufer Hospital, for the years 1970-72 there were 240 cases of viral hepatitis thus accounting for 0.7% of the total admissions with a mortality of 6%. The incidence according to Viswanathan et al is 1.2%27. The reasons for the higher incidence reported by other authors may be that only moderate to severe cases are admitted in hospital. Further, there is a higher incidence of anicteric cases in children which have not been included in the statistics. It should be remembered that in children one case of icteric viral hepatitis represents 12 cases of the anicteric type (Krugman 1962)10. Though it has been mentioned that viral hepatitis is often a self limiting disease mortality is high during epidemics16 and even higher in adults.
In the present study, patients ranged from 1–12 years. A higher incidence has been noticed during the pre-school period in the present series, as also by Dave et al3. But a higher incidence during the school age was observed by Nelson and Deshpande et al4. A higher incidence was noticed during the late summer and winter months, which agrees with the observations of other workers27.
TYPICAL PRE-TREATMENT MICROPHOTOGRAPHS
Eighty five per cent of the present series belonged to poor socio-economic status and 15% to the middle income group. This is attributed to poor sanitation and bad personal hygiene in these groups. History of contact was obtained in about 16% of cases. Absence of this history in other cases is probably due to the occurrence of anicteric cases and mild jaundice which may not be noticed due to ignorance. In the present series the illness was of sudden onset in 63% and insidious in 37% of cases. The mode of onset has been described by Mallory14 and Lichtman12 as follows: (1) acute infectious type (2) gastrointestinal type (3) mixed (4) cerebral symptoms. The most frequent prodromal symptoms in the present series were gastro-intestinal (46%), respiratory symptoms (23%). About 6% of the cases were brought with neuropsychiatric symptoms and the rest with constitutional symptoms.
In India, 90% of jaundice is due to viral hepatitis3. This was observed in all cases of the present series but in 5% it could be detected only after admission. Table 6 shows the duration of jaundice prior to admission, the average being 10 days. Jaundice was preceded by a history of passing highly coloured urine 1–8 days before, in most of the cases. Pyrexia was noted in 91.6% of the present series, but it continued into the icteric stage only in about 45% of the cases. Lichtman attributes fever to necrosis of hepatic cells, secondary infection of bile channels and necrotic foci, and enteritis with lymphangitic infection of the mesentery12. Weakness and fatiguability was noticed in 75% of the cases. Asthenia was attributed to disturbed myoneural physiology by retained bile salts; a disturbance in carbohydrate metabolsim which leads to delayed conversion of lactic acid to glycogen stores and to vitamin E deficiency due to lack of absorption12. Anorexia is one of the presenting features of viral hepatitis (Sherlock)24. This was observed in 70% of the present series and 40% as observed by Sule et al26. The average duration of anorexia prior to admission was 16 days but varied from 2–60 days. Infants refused feeds. Anorexia was more marked for fatty foods in older children. The return of appetite is an index of recovery.
Vomiting was observed in 47% of the cases and nausea in 33% of the series. These were related to food in most of the cases and more prominent during the prodromal stage. Diarrhoea was encountered in 46% of the present series and 20% had diarrhoea associated with vomiting. A single case was admitted only for gastroenteritis and jaundice could be detected only on the day after admission. Diarrhoea is attributed to the presence of intestinal cattarrh and is common in children, though according to Nelson constipation is more common than diarrhoea17. Constipation was encountered in 5% of the cases only. This is more often seen in adults. The history of passing clay coloured stools was obtained in about 56% of the present series and suggests the obstructive phase of viral hepatitis due to ballooning of the hepatocytes.
Role of Liv.52 and Steroids in the Management of Viral Hepatitis in Children
Reddi, Y.R., M.D., M.A.M.S., Professor and Head of the Department of Paediatrics, Osmania Medical College, Director of Paediatric Services, Institute of Child Health and Superintendent, Niloufer Hospital, Hyderabad, India. Rohini, K., M.D., D.C.H., Research Scholar, Kusuma, G., M.D., D.C.H., Assistant Professor of Paediatrics and Sudhakar Rao, V., M.D. (Ped.), D.C.H. (Bom.), D.A.B.P. (U.S.A.), F.A.A.P. Assistant Professor of Paediatrics Research.
DISCUSSION
Out of 28339 cases admitted in the children’s ward of Niloufer Hospital, for the years 1970-72 there were 240 cases of viral hepatitis thus accounting for 0.7% of the total admissions with a mortality of 6%. The incidence according to Viswanathan et al is 1.2%27. The reasons for the higher incidence reported by other authors may be that only moderate to severe cases are admitted in hospital. Further, there is a higher incidence of anicteric cases in children which have not been included in the statistics. It should be remembered that in children one case of icteric viral hepatitis represents 12 cases of the anicteric type (Krugman 1962)10. Though it has been mentioned that viral hepatitis is often a self limiting disease mortality is high during epidemics16 and even higher in adults.
In the present study, patients ranged from 1–12 years. A higher incidence has been noticed during the pre-school period in the present series, as also by Dave et al3. But a higher incidence during the school age was observed by Nelson and Deshpande et al4. A higher incidence was noticed during the late summer and winter months, which agrees with the observations of other workers27.
Normal liver cell pattern L.P. 10 x 10 |
TYPICAL PRE-TREATMENT MICROPHOTOGRAPHS
Infiltration of the portal tract by mononuclear cells and leucocytes L.P. 10 x 10 |
Ballooning of the hepatocytes L.P. 10 x 10 |
Case No. 29 (Group A – Liv.52) Initial Biopsy showing infiltration of the portal tract by mononuclear cells. L.P. 10 x 10 |
Case No. 29 (Group A – Liv.52) Repeat Biopsy showing recovery. L.P. 10 x 10 |
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Case No. 3 (Group A – Liv.52) Initial Biopsy showing mononuclear infiltration of the portal tracts. H.P. 10 x 10 |
Case No. 3 (Group A – Liv.52) Repeat Biopsy shows recovery. L.P. 10 x 10 |
Case No. 27 (Group B – Prednisone) Initial Biopsy showing periportal infiltration. L.P. 10 x 10 |
Case No. 27 (Group B – Prednisone) Repeat Biopsy showing perisistence of the lesion. L.P. 10 x 10 |
Case No. 39 (Group D - Supportive therapy) Initial Biopsy showing fibroblastic reaction mononuclear infiltration of the portal tracts. L.P. 10 x 10 |
Case No. 39 (Group D - Supportive therapy) Repeat Biopsy showing persistence of the lesion. L.P. 10 x 10 |
Eighty five per cent of the present series belonged to poor socio-economic status and 15% to the middle income group. This is attributed to poor sanitation and bad personal hygiene in these groups. History of contact was obtained in about 16% of cases. Absence of this history in other cases is probably due to the occurrence of anicteric cases and mild jaundice which may not be noticed due to ignorance. In the present series the illness was of sudden onset in 63% and insidious in 37% of cases. The mode of onset has been described by Mallory14 and Lichtman12 as follows: (1) acute infectious type (2) gastrointestinal type (3) mixed (4) cerebral symptoms. The most frequent prodromal symptoms in the present series were gastro-intestinal (46%), respiratory symptoms (23%). About 6% of the cases were brought with neuropsychiatric symptoms and the rest with constitutional symptoms.
In India, 90% of jaundice is due to viral hepatitis3. This was observed in all cases of the present series but in 5% it could be detected only after admission. Table 6 shows the duration of jaundice prior to admission, the average being 10 days. Jaundice was preceded by a history of passing highly coloured urine 1–8 days before, in most of the cases. Pyrexia was noted in 91.6% of the present series, but it continued into the icteric stage only in about 45% of the cases. Lichtman attributes fever to necrosis of hepatic cells, secondary infection of bile channels and necrotic foci, and enteritis with lymphangitic infection of the mesentery12. Weakness and fatiguability was noticed in 75% of the cases. Asthenia was attributed to disturbed myoneural physiology by retained bile salts; a disturbance in carbohydrate metabolsim which leads to delayed conversion of lactic acid to glycogen stores and to vitamin E deficiency due to lack of absorption12. Anorexia is one of the presenting features of viral hepatitis (Sherlock)24. This was observed in 70% of the present series and 40% as observed by Sule et al26. The average duration of anorexia prior to admission was 16 days but varied from 2–60 days. Infants refused feeds. Anorexia was more marked for fatty foods in older children. The return of appetite is an index of recovery.
Vomiting was observed in 47% of the cases and nausea in 33% of the series. These were related to food in most of the cases and more prominent during the prodromal stage. Diarrhoea was encountered in 46% of the present series and 20% had diarrhoea associated with vomiting. A single case was admitted only for gastroenteritis and jaundice could be detected only on the day after admission. Diarrhoea is attributed to the presence of intestinal cattarrh and is common in children, though according to Nelson constipation is more common than diarrhoea17. Constipation was encountered in 5% of the cases only. This is more often seen in adults. The history of passing clay coloured stools was obtained in about 56% of the present series and suggests the obstructive phase of viral hepatitis due to ballooning of the hepatocytes.
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