Bilal Muhammad, Ajmal Muhammad Usman, Ali Ahtisham
Paediatrics, Farooq Hospital, West Wood Branch, Lahore, Lahore, PAK.
Paediatrics, University of Child Health Sciences and The Children's Hospital, Lahore, Lahore, PAK.
Cureus. 2025 Aug 3;17(8):e89310. doi: 10.7759/cureus.89310. eCollection 2025 Aug.
Hepatitis A virus (HAV) typically causes a self-limiting illness in children. Rarely, it can progress to fulminant hepatic failure (FHF), and even less commonly, may be followed by features suggestive of autoimmune hepatitis (AIH). The diagnostic overlap can be particularly challenging in tropical regions, where endemic infections such as dengue and malaria may present with similar clinical features. We report a previously healthy five-year-old girl who presented with a four-day history of high-grade fever, abdominal pain, vomiting and lethargy. Examination revealed pallor, icterus, hepatosplenomegaly, and right-sided pleural effusion. Initial investigations showed thrombocytopenia, leukopenia, and ascites, prompting a provisional diagnosis of dengue hemorrhagic fever. However, dengue serology was negative. Further workup revealed HAV IgM positivity and Plasmodium vivax parasitemia. Her condition worsened with bilateral pleural effusions and altered mental status, consistent with mild hepatic encephalopathy. She was managed conservatively without liver transplantation using intravenous antibiotics, oral antimalarials, lactulose, rifaximin, and transfusional support. Clinical stabilisation was achieved, and she was discharged. Persistent transaminitis on follow-up prompted further evaluation, revealing antinuclear antibody (ANA) positivity (1:320, speckled), suggestive of evolving type 1 AIH. Oral corticosteroid therapy was initiated, leading to a favourable response. She continues on outpatient follow-up with improving liver function. While definitive confirmation of AIH was limited by the absence of serum IgG, smooth muscle antibody (SMA), and liver biopsy, the findings were suggestive of an evolving autoimmune process. This case highlights the diagnostic pitfalls in co-endemic regions and underscores the importance of re-evaluating children with persistently elevated liver enzymes following acute viral hepatitis.
甲型肝炎病毒（HAV）通常在儿童中引起自限性疾病。极少数情况下，它会进展为暴发性肝衰竭（FHF），更罕见的是，之后可能会出现提示自身免疫性肝炎（AIH）的特征。在热带地区，诊断重叠可能特别具有挑战性，因为登革热和疟疾等地方性感染可能表现出相似的临床特征。我们报告了一名此前健康的5岁女孩，她有4天的高热、腹痛、呕吐和嗜睡病史。检查发现面色苍白、黄疸、肝脾肿大和右侧胸腔积液。初步检查显示血小板减少、白细胞减少和腹水，提示初步诊断为登革出血热。然而，登革热血清学检查为阴性。进一步检查发现HAV IgM阳性和间日疟原虫血症。她的病情因双侧胸腔积液和精神状态改变而恶化，符合轻度肝性脑病。她接受了保守治疗，未进行肝移植，使用了静脉抗生素、口服抗疟药、乳果糖、利福昔明和输血支持。病情实现了临床稳定，她出院了。随访中持续的转氨酶升高促使进一步评估，发现抗核抗体（ANA）阳性（1:320，斑点状），提示1型AIH正在发展。开始口服皮质类固醇治疗，产生了良好的反应。她继续在门诊随访，肝功能不断改善。虽然由于缺乏血清IgG、平滑肌抗体（SMA）和肝活检，对AIH的明确确诊受到限制，但这些发现提示了自身免疫过程正在发展。该病例突出了共流行地区的诊断陷阱，并强调了对急性病毒性肝炎后肝酶持续升高的儿童进行重新评估的重要性。
