Acute hepatitis of unknown etiology in an adult female:A case report

BACKGROUND Acute liver injury(ALI)refers to inflammation of the hepatic parenchyma without hepatic encephalopathy that lasts less than 6 mo.When the etiology is unknown,Acute Hepatitis of Unknown Origin(AHUO)can present as a diagnostic and treatment challenge.AHUO in the adult population is unusual and poorly documented.It has an incidence between 11%and 75%.Currently,no treatment guidelines exist.With no identified cause,treatment is often blind,and the wrong treatment plan may have unintended consequences.CASE SUMMARY We present the case of a 58-year-old woman who presented to the emergency room for elevated liver function tests(LFTs).Her symptoms started 10 d prior to admission and included nausea,vomiting,jaundice,decreased appetite,weight loss of 10 lbs,and dark urine.She denied drinking alcohol or taking any hepatotoxic agents,including acetaminophen,statins,vitamins,or supplements.She was admitted to the hospital,and an etiologic work-up was carried out.Her initial bloodwork revealed elevated liver enzymes(alanine aminotransferase 2500 U/L,aspartate aminotransferase 3159 U/L,and alkaline phosphatase 714 U/L)and elevated total bilirubin of 6.4 mg/dL.She tested negative for common infectious etiologies such as hepatotropic viruses A,B,C,and E.Further infective work-up revealed negative serology for cytomegalovirus,Epstein-Barr virus,herpes simplex virus 1&2,and human immunodeficiency virus.Her autoanti-body test results were negative,including anti-smooth muscle antibody,anti-mitochondrial antibody,and anti-liver kidney microsome 1 antibody.Magnetic resonance cholangiopancreatography ruled out biliary causes of elevated LFTs,and her core liver biopsy proved inconclusive.Over the course of her hospital stay,the patient's LFTs improved with supportive care and without steroids.CONCLUSION Idiopathic hepatitis makes treatment challenging.It can leave patients feeling confused and unfulfilled.Thus,educating the patient thoroughly for shared decision-making and management becomes essential.

May 2022 acute hepatitis outbreak,is there a role for COVID-19 and other viruses?

There has been an increasing number of reported cases of acute hepatitis of unknown origin in previously healthy children since first reported on March 31,2022.This clinical syndrome is identified by jaundice and markedly elevated liver enzymes with increased aspartate transaminase and/or alanine aminotransa-minase(greater than 500 IU/L).We conducted an inclusive literature review with respect to acute hepatitis outbreaks in children using the search terms acute hepatitis,outbreak,children,severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),coronavirus disease 2019(COVID-19),and adenovirus.According to the cumulative data presented in four main studies,the median age is 4 years,with a male predominance(1.3:1).Jaundice was the most common clinical manifestation(69%),followed by vomiting(63%),anorexia(52.9%),diarrhea(47.2%),abdominal pain(39%),pyrexia(33.3%),pale stool(30%),and dark urine(30%).Coryza and lethargy were reported in 16.6%,while pruritus was reported in 2%of cases.Acute liver failure was observed in 25%of cases.The exact mechanism of this acute hepatitis outbreak is still not entirely clear.Adenoviruses and SARS-CoV-2 were detected in a significant number of patients.Coinfection with adenovirus and SARS-CoV-2 could be a possible underlying mechanism.However,other possible infections and mechanisms must be considered in the pathogenesis of this condition.Acute hepatitis of unknown origin in children has been a serious problem since the start of the COVID-19 pandemic but has not yet been sufficiently addressed.Many questions remain regarding the underlying mechanisms leading to acute liver failure in children,and it is likely that extensive future research is needed.

Autoimmune hepatitis triggered by acute hepatitis A

The patient was a 57-year-old woman presenting with jaundice as the chief complaint. She began vomiting on July 10, 2003. Jaundice was noted and admitted to our hospital for thorough testing. Tests on admission indicated severe hepatitis, based on： aspartate aminotransferase （AST）, 1 076 IU/L; alanine aminotransferase （ALT）, 1 400 IU/L; total bilirubin （TB）, 20.9 mg/dL; and prothrombin time rate （PT%）, 46.9%. Acute hepatitis A （HA） was diagnosed based on negative hepatitis B surface antigen and hepatitis C virus RNA and positive immunoglobulin （Ig） M HA antibody, but elevation of anti-nuclear antigen （×320） and IgG （3 112 mg/dL） led to suspicion of autoimmune hepatitis （AIH）. Plasma exchange was performed for 3 d from July 17, and steroid pulse therapy was performed for 3 d starting on July 18, followed by oral steroid therapy. Liver biopsy was performed on August 5, and the results confirmed acute hepatitis and mild chronic inflammation. Levels of AST and ALT normalized, so dose of oral steroid was markedly reduced. Steroid therapy was terminated after 4 mo, as the patient had glaucoma. Starting 3 mo after cessation of steroid therapy, levels of AST and ALl began to increase again. Another liver biopsy was performed and AIH was diagnosed based on serum data and biopsy specimen. Oral steroid therapy was reinitiated. Levels of AST and ALT again normalized. The present case was thus considered to represent AIH triggered by acute HA.

Clinical features and risk factors of acute hepatitis E with severe jaundice

AIM:To compares the clinical features of patients infected with hepatitis E virus(HEV) with or without severe jaundice.In addition,the risk factors for HEV infection with severe jaundice were investigated.METHODS:We enrolled 235 patients with HEV into a cross-sectional study using multi-stage sampling to select the study group.Patients with possible acute hepatitis E showing elevated liver enzyme levels were screened for HEV infection using serologic and molecular tools.HEV infection was documented by HEV antibodies and by the detection of HEV-RNA in serum.We used χ2 analysis,Fisher's exact test,and Student's t test where appropriate in this study.Significant predictors in the univariate analysis were then included in a forward,stepwise multiple logistic regression model.RESULTS:No significant differences in symptoms,alanine aminotransferase,aspartate aminotransferase,al-kaline phosphatase,or hepatitis B virus surface antigen between the two groups were observed.HEV infected patients with severe jaundice had significantly lower peak serum levels of γ-glutamyl-transpeptidase(GGT)(median:170.31 U/L vs 237.96 U/L,P = 0.007),significantly lower ALB levels(33.84 g/L vs 36.89 g/L,P = 0.000),significantly lower acetylcholine esterase(CHE) levels(4500.93 U/L vs 5815.28 U/L,P = 0.000) and significantly higher total bile acid(TBA) levels(275.56 μmol/L vs 147.03 μmol/L,P = 0.000) than those without severe jaundice.The median of the lowest point time tended to be lower in patients with severe jaundice(81.64% vs 96.12%,P = 0.000).HEV infected patients with severe jaundice had a significantly higher viral load(median:134 vs 112,P = 0.025) than those without severe jaundice.HEV infected patients with severe jaundice showed a trend toward longer median hospital stay(38.17 d vs 18.36 d,P = 0.073).Multivariate logistic regression indicated that there were significant differences in age,sex,viral load,GGT,albumin,TBA,CHE,prothrombin index,alcohol overconsumption,and duration of admission between patients infected with acute hepatitis E with and without severe jaundice.CONCLUSION:Acute hepatitis E patients may naturally present with severe jaundice.

Acute hepatitis B of genotype H resulting in persistent infection

A 47-year-old man presented with general fatigue and dark urine.The laboratory data showed increased levels of hepatic transaminases.The patient was positive for hepatitis B virus(HBV)markers and negative for antihuman immunodeficiency virus.The HBV-DNA titer was set to 7.7 log copies/mL.The patient was diagnosed with acute hepatitis B.The HBV infection route was obscure.The serum levels of hepatic transaminases decreased to normal ranges without any treatment,but the HBVDNA status was maintained for at least 26 mo,indicating the presence of persistent infection.We isolated HBV from the acute-phase serum and determined the genome sequence.A phylogenetic analysis revealed that the isolated HBV was genotype H.In this patient,the elevated peak level of HBV-DNA and the risk alleles at human genome single nucleotide polymorphisms s3077and rs9277535 in the human leukocyte antigen-DP locus were considered to be risk factors for chronic infection.This case suggests that there is a risk of persistent infection by HBV genotype H following acute hepatitis;further cases of HBV genotype H infection must be identified and characterized.Thus,the complete determination of the HBV genotype may be essential during routine clinical care of acute hepatitis B outpatients.

Sustained viral response of a case of acute hepatitis C virus infection via needle-stick injury

A 29-year-old nurse with a hepatitis C virus （HCV） infection caused by needle-stick injury was treated with interferon-beta starting about one year after the onset of acute hepatitis. The patient developed acute hepatitis C with symptoms of general fatigues, jaundice, and ascites 4 wk after the needle-stick injury. When these symptoms were presented, the patient was pregnant by artificial insemination. She hoped to continue her pregnancy. After delivery, biochemical liver enzyme returned to normal levels. Nevertheless, HCV RNA was positive and the pathological finding indicated a progression to chronicity. The genotype was lb with low viral load. Daily intravenous injection of interferon-beta at the dosage of six million units was started and continued for eight weeks. HCV was eradicated without severe adverse effects. In acute hepatitis C, delaying therapy is considered to reduce the efficacy but interferon-beta therapy is one of the useful treatments for hepatitis C infection in chronic phase.

Acute hepatitis C:Prospects and challenges

More than 170 million people worldwide have chronic hepatitis C. Acute hepatitis C is rarely diagnosed because it is commonly asymptomatic. Most infected patients are unaware of their condition until the symptoms of chronic infection manifest. Treatment of acute hepatitis C is something of a paradox because spontaneous resolution is possible and many patients do not have symptoms. However, several factors provide a rationale for treating patients who have acute hepatitis C. Compared with acute hepatitis C, chronic hepatitis C is associated with a worse prognosis, the need for more intensive treatment, longer treatment duration, and a decrease in successful treatment outcomes. Conversely, early intervention is associated with improved viral eradication, using a regimen that is better tolerated, less expensive, more convenient, and of shorter duration than the currently approved combination therapies for chronic hepatitis C.

An Analysis of Epidemiological Characteristics and the Clinical Features of 394 Cases of Sporadic Acute Hepatitis E in Southwest China from 2008 to 2010

Background and Aims Recently, epidemiology studies of hepatitis E in different areas are attracted more attention. Extensive studies of prevalent status and clinical manifestations could help us to broaden our knowledge, so as to excellently prevent and treat hepatitis E. The study analyzed the epidemiological characteristics and clinical features of 394 cases of sporadic acute hepatitis E(AHE) in Southwest of China from 2008 to 2010. Methods The clinical data of 394 cases with sporadic AHE in Southwest of China from 2008 to 2010 were reviewed.Results In the 394 cases with sporadic AHE, the ratio of male/female was 1.432∶1, and the mean age was(31.53 ± 18.12) years. Totally, 94(23.86%) patients aged under 18, 271(68.78%) patients aged between 18 and 60, and 29(7.36%) patients aged above 60. The incidence rate was significantly increased in summer(P = 0.000), especially in May(14.72%) and July(13.71%). In addition, the characteristics of occupation and ethnic group distribution were migrant laborers(106/394, 26.90%) and Han people(365/394, 92.64%). The length of stay, incidence of jaundice, the peak value of total bilirubin and alanine aminotransferase in male patients were all higher than those in female patients significantly(P < 0.05). The prolonged length of stay, decreased levels of ALT/ALB/CHE, increased levels of TBil, and increased incidence of jaundice and fatigue were associated with older age significantly(P < 0.05). The differences in peak values of total bilirubin(TBil), total bile acid(TBA), glutamyltransferase(GGT), cholinesterase(CHE) between AHE group and the groups of AHE accompanied respectively by chronic hepatitis B(CHB), acute alcoholic fatty liver(AFL), nonalcoholic fatty liver disease(NAFLD) were significant(P < 0.05). In addition, no significant difference was found in length of stay and biochemical indexes among anti-HEV-Ig G positive group, anti-HEV-Ig M positive group and antiHEV-Ig M/Ig G both positive group(P > 0.05).Conclusions Four epidemiological characteristics, including aged between 18 and 60, male, summer and migrant laborers, are found to be associated with acute hepatitis E. The prognosis of AHE in the majority of patients was favorable, but aged above 60 years and coexistence with CHB, AFL and NAFLD could be considerede as the factors inducing the infaust prognosis.

SARS-CoV-2:Possible role in children with acute hepatitis of unknown origin

The UK raised an alert with the World Health Organization(WHO)in April 2022 concerning a significant surge in the num-ber of children diagnosed with acute hepatitis of unknown origin(AHUO).Despite an ongoing investigation attributing its etiology to adenovirus infection,the absence of adenovirus inclusions in liver biopsies and the remarkably low viral load raised doubts.Concurrently,reports of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infections in children coincided with the surge in acute hepatitis cases,prompting the need for a thorough examination of the poten-tial connection between current or past SARS-CoV-2 infections and pediatric hepatitis epidemics.Epidemiological data suggests that acute hepatitis is a notable manifestation of the multiple-system inflammatory syndrome in children following the global SARS-CoV-2 pandemic.However,the precise role of the SARS-CoV-2 virus in liver injury etiology remains uncertain.To shed light on the potential association between SARS-CoV-2 and AHUO in children,we conduct-ed a systematic review of epidemiological links,potential pathogenesis,and recent research findings,aiming to raise awareness and vigilance among clinicians.Convincing and definitive evidence will be essential in the future to confirm the direct impact of SARS-CoV-2 infection on children with AHUO.

Epidemiology of acute and chronic hepatitis B and delta over the last 5 decades in Italy

The spread of hepatitis B virus(HBV)infection has gradually decreased in Italy in the last 5 decades as shown by the steady reduction in the incidence rates of acute hepatitis B,from 10/100000 inhabitants in1984 to 0.85/100000 in 2012,and by the reduced prevalence of hepatitis B surface antigen(HBsAg)-positive cases among chronic hepatitis patients with different etiologies,from 60%in 1975 to about 10%in 2001.The prevalence of HBsAg chronic carriers in the general population also decreased from nearly 3%in the 1980s to 1%in 2010.Linked to HBV by its characteristics of defective virus,the hepatitis delta virus(HDV)has shown a similar epidemiological impact on the Italian population over time.The incidence of acute HDV infection decreased from 3.2/100000 inhabitants in 1987 to 0.8/100000 in 2010 and the prevalence of HDV infection in HBsAg chronic carriers decreased from24%in 1990 to 8.5%in 2006.Before the beneficial effects of HBV mass vaccination introduced in 1991,the decreased endemicity of HBV and HDV infection in Italy paralleled the improvement in screening blood donations,the higher standard of living and impressive reduction in the birth rate associated with a marked reduction in the family size.A further contribution to the decline in HBV and HDV infections most probably came from the media campaigns to prevent the spread of human immunodeficiency virus infection by focusing the attention of the general population on the same routes of transmission of viral infections such as unsafe sexual intercourse and parenteral exposures of different kinds.

Profiling the repertoire of T-cell receptor beta-chain variable genes in peripheral blood lymphocytes from subjects who have recovered from acute hepatitis B virus infection

The profile of T-cell receptor beta-chain variable （TRBV） genes usually skews in subjects with virus infection or cancer. The gene melting spectral pattern （GMSP） can be used to determine the profile of the TRBV gene family. To explore the portrait of the TRBV family in peripheral blood lymphocytes from subjects who have recovered from acute hepatitis B virus infection （AHI）, peripheral blood mononuclear cells （PBMCs） were separated and further sorted into CD4^＋ and CD8^＋ T-cell subsets. The molecular features of the TRBV complementary determining region 3 （CDR3） motifs were determined using GMSP analysis. When a GMSP profile showed a single peak, the monoclonally expanded TRBV gene was cloned and sequenced. Skewed expansions of multiple TRBV genes were observed among the CD4^＋ and CD8^＋ T-cell subsets and the PBMCs. The frequency of monoclonally expanded TRBV genes in the CD8^＋ T-cell subset was significantly higher than that of the CD4^＋ T-cell subset and the PBMCs. Compared to other members of the TRBV gene family, TRBV11, BV15 and BV20 were predominantly expressed in the repertoire of peripheral blood lymphocytes in recovered AHI subjects. The relatively conserved amino acid motifs of TRBV5.1 and BV20 CDR3 were also detected in the CD4^＋ and CD8^＋ T-cell subsets. These results demonstrate the presence of multiple biased TRBV families in recovered AHI subjects. TRBV11, BV15 and BV20, especially from the CD8＋ T-cell subset, may be relevant to the pathogenesis of subjects with AHh The preferentially selected TRBV5.1 and BV20 with the relatively conserved CDR3 motif may be potential targets for personalized treatments of chronic HBV infection.

Diagnosis,treatment,and prevention of severe acute hepatitis of unknown etiology in children

Background Severe acute hepatitis of unknown etiology in children has recently exhibited a global trend of concentrated occurrence.This review aimed to summarize the current available information regarding the outbreak of severe acute hepatitis and introduce our hospital’s previous experiences with the diagnosis and treatment of severe acute hepatitis for reference.Data sources Websites including the UK Health Security Agency,European Centre for Disease Prevention and Control,CDC,WHO,and databases including PubMed/Medline,Cochrane Library,Embase and Web of Science were searched for articles on severe acute hepatitis in children.Results As of May 26,2022,a total of 650 cases have been reported in 33 countries;at least 38(6%)children required liver transplantation,and nine(1%)died.Cases are predominantly aged between 3 and 5 years old,and there are no epidemiological links among them.The common manifestations are jaundice,vomiting and pale stools.Adenovirus tested positive in most cases,and SARS-CoV-2 and other viruses were detected in a few cases,but virus particles were not found in liver tissue.Adenovirus immunohistochemistry showed immunoreactivity in the intrasinusoidal lumen from some liver samples.The hierarchical treatment includes symptomatic and supportive therapy,management of coagulation disorders and hepatic encephalopathy,artifcial liver support,and liver transplantation(approximately 6%–10%of cases require liver transplant).Conclusions The etiology of this severe acute hepatitis in children is not clear.The clinical features are severe acute hepatitis with signifcantly elevated liver enzymes.Clinicians need to be alert to children with hepatitis.

Centrilobular necrosis in acute presentation of Japanese patients with type 1 autoimmune hepatitis

AIM: To compare clinicopathological features of acute presentation of type 1 autoimmune hepatitis (AIH) with or without centrilobular necrosis (CN). METHODS: Our study comprised 41 patients with biopsy-proven acute presentation (acute exacerbation phase 36, acute hepatitis phase 5) of type 1 AIH at our hospital from 1975 to 2009. Elevated serum alanine aminotransferase (ALT) (> 5x upper limit of normal) identified acute presentation of the disease. We compared clinicopathological features of these AIH patients with or without CN. The data used for analysis included patient background (age, sex, type of disease, presence of complications with other autoimmune diseases, human leukocyte antigen, and International Autoimmune Hepatitis Group score), clinical parameters at presentation (ALT, alkaline phosphatase, IgG, anti-nuclear antibodies, and anti-smooth muscle antibodies), histology and therapy. RESULTS: CN was found in 13 (31.7%) patients with acute presentation (acute exacerbation phase 10, acute hepatitis phase 3) of AIH. Serum IgG levels of patients with CN were significantly lower than those of patients without CN (mean: 2307 mg/dL vs 3126 mg/dL, P < 0.05), while antinuclear antibody-negative rates were significantly higher (30.7% vs 3.5%, P < 0.05). However, other clinical features were similar between the two groups. The frequency of advanced fibrosis in patients with CN was significantly lower than in patients without CN (F0-2: 84.6% vs 35.7%, F3-4: 15.4% vs 64.3%, P < 0.05). Other histological features were similar between the two groups. Although there was no significant difference between groups when evaluated using the revised original score (12 vs 14), the simplified AIH score of patients with CN was significantly lower (6 vs 7, P < 0.05). Frequency of DR4 was similar between patients with and without CN. CONCLUSION: CN is observed in both Japanese patients with acute hepatitis phase and acute exacerbation phase of type 1 AIH, although AIH with CN often shows clinical features of the genuine acute form.

Acute pancreatitis in acute viral hepatitis

AIM: To elucidate the frequency and characteristics of pancreatic involvement in the course of acute (nonfulminant) viral hepatitis. METHODS: We prospectively assessed the pancreatic involvement in patients with acute viral hepatitis who presented with severe abdomimanl pain. RESULTS: We studied 124 patients with acute viral hepatitis, of whom 24 presented with severe abdominal pain. Seven patients (5.65%) were diagnosed to have acute pancreatitis. All were young males. Five patients had pancreatitis in the first week and two in the fourth week after the onset of jaundice. The pancreatitis was mild and all had uneventful recovery from both pancreatitis and hepatitis on conservative treatment. The etiology of pancreatitis was hepatitis E virus in 4, hepatitis A virus in 2, and hepatitis B virus in 1 patient. One patient had biliary sludge along with HEV infection. The abdominal pain of remaining seventeen patients was attributed to stretching of Glisson's capsule. CONCLUSION: Acute pancreatitis occurs in 5.65% of patients with acute viral hepatitis, it is mild and recovers with conservative management.

Severe acute hepatitis of unknown causes in children–Current findings,questions,opinions,and recommendations,a mini-review

Since October 2021 in Alabama,the United States,and March 2022 in central Scotland,the United Kingdom,the number of cases of severe acute hepatitis of unknown etiology/causes in children was found to increase,and the total number of cases has reached 920 worldwide by June 22 this year,45 cases(5%)required liver transplantation,and 18 cases(2%)died according to World Health Organization(WHO).To understand the basic characteristics of this disease/syndrome,a literature search was performed at PubMed,websites of WHO,UK Health Security Agency,and US and European Centers for Disease Control and Prevention,and more than 20 reports were enrolled as references for this review.The main clinical manifestations are anorexia,vomiting,fatigue,jaundice,and so forth.Most of the cases seemed to have a self-limited course of the disease,about 6%of cases may develop life-threatening acute liver failure.The disease seems to be transmissible from person to person.Human adenovirus was detected in up to 75%of cases,but this virus seems not to be the only and major etiologic agent,other cofactors probably are involved.Researchers proposed many hypotheses concerning the etiology and pathogenesis,and many important works and studies are ongoing.This mini-review is aimed at summarizing,reviewing,and further understanding the characteristics of the disease,raising some clinically relevant questions,and trying to discuss some questions that may be related to the treatment of the disease for consideration.

Expert symposium on severe acute hepatitis of unknown cause in children,a paradigm of exchanges and sharing between Chinese and Western medicine professionals

Recently,cases of severe acute hepatitis of unknown cause(SAHUC)in children have suddenly increased in the United States,the United Kingdom,and other countries.In order to understand the progress in the diagnosis and treatment of this disease,and to prepare for the relevant plans in advance,the“Expert Symposium on the Severe Acute Hepatitis of Unknown Cause in Children”was successfully held on May 13,2022,online organized by Beijing Children's Hospital(BCH),Capital Medical University,Beijing Institute of Pediatrics Integrated Chinese and Western Medicine,Futang Research Center of Pediatric Development,and Branch of Hepatobiliary Diseases,China Association of Chinese Medicine.More than 9200 people watched the meeting online.Professors Yan Hu,Yan Yang,and Jing Hao,from the Department of Traditional Chinese Medicine(TCM),BCH,Capital Medical University,hosted the symposium.

Acute hepatitis of unknown aetiology among children around the world

By 26 August 2022, the number of cases of acute hepatitis of unknown etiology (AHUA) has drastically increased to 1115 distributed in 35 countries that fulfill the World Health Organization definition. Several hypotheses on the cause of AHUA have been proposed and are being investigated around the world. In the recent United Kingdom (UK) report, human adenovirus (HAdV) with adeno-associated virus (AAV) co-infection is the leading hypothesis. However, there is still limited evidence in establishing the causal relationship between AHUA and any potential aetiology. The leading aetiology continues to be HAdV infection. It is reported that HAdV genomics is not unusual among the population in the UK, especially among AUHA cases. Expanding the surveillance of HAdV and AAV in the population and the environment in the countries with AUHA cases is suggested to be the primary action. Metagenomics should be used in detecting other infectious pathogens on a larger scale, to supplement the detection of viruses in the blood, stool, and liver specimens from AUHA cases. It is useful to develop a consensus-specific case definition of AHUA to better understand the characteristics of these cases globally based on all the collected cases.

Acute cytomegalovirus hepatitis in an immunocompetent patient:A case report

BACKGROUND Cytomegalovirus(CMV)infection is usually subclinical and asymptomatic in the healthy population,whereas severe complications occur in immunocompromised patients.CASE SUMMARY In this case report,we described a rare case of acute CMV hepatitis in a 35-yearold male immunocompetent patient who presented with a history of week-long intermittent fever with nonspecific constitutional symptoms.Acute hepatitis was suspected according to the initial serological tests.After ruling out other etiologies,including viral hepatitis A,B,C,drug,alcohol,autoimmune,and Wilson disease,acute CMV hepatitis was diagnosed based on positive CMV IgM and DNA quantitative tests.Because there was no any local acute hepatitis E reported in Taiwan,so hepatitis E was not checked.The patient recovered both clinically and serologically with symptomatic management and without antiviral therapy within 12 days from the onset of symptom.CONCLUSION In conclusion,a diagnosis of CMV infection should be considered when nonspecific prodromal symptoms occur in acute hepatitis with an uncertain etiology.Antiviral therapy should not be used in immunocompetent patient who had no decompensation of the liver,such as this patient.Widely available noninvasive tests for CMV can facilitate early diagnosis if used appropriately.Harm–benefit analysis is essential before using antiviral therapy in immunocompetent patients.

Acute Syphilitic Hepatitis in the Early Secondary Phase: A Case Report and Literature Review

Background: The incidence of syphilis is clearly increasing. It is a source of visceral damage, particularly in the secondary phase. Acute syphilitic hepatitis is a rare clinical entity classically described but under-diagnosed because of its non-specific presentation. Case Presentation: We report the case of a 25-year-old French woman, without comorbidity, sexually active, having unprotected sex with only one partner. She was admitted to our unit for jaundice and a disturbed liver function test preceded 3 weeks earlier by a rash. The patient did not consume alcohol and did not report the introduction of a new medication. A skin rash compatible with syphilitic roseola and generalized adenopathy were found. The liver workup showed alanine aminotransferase (ALT) at 1984 U/L, aspartate aminotransferase (AST) at 1377 U/L, total bilirubin at 221 μmol/L, alkaline phosphatase activity (APL) at 419 U/L, gamma glutamyl transferase activity (GGT) at 229 U/L and a prothrombin concentration at 73%. The search for the most common etiologies of acute hepatitis was negative. Syphilitic serology was positive with a Treponema Pallidum Hemagglutinations Assay (TPHA) titration of 5120 IU and Veneral Disease Research Laboratory (VDRL) of 64 IU. Abdominal ultrasound revealed only homogeneous hepatomegaly and splenomegaly with no focal lesions. Other sexually transmitted infections (STI) were negative and her partner had positive syphilis serology. After a single dose of Benzathine benzylpenicillin, the clinical signs regressed after one week and the hepatic balance tended to normalize 20 days later. Conclusion: This highlights the need for a high index of suspicion for syphilitic hepatitis in sexually active patients presenting with acute hepatitis associated with a cutaneous rash.

Trained innate immunity and human adenovirus infection as a novel mechanism linked to the severe acute hepatitis of unknown origin in children during the COVID‐19 pandemic

1|OUTBREAK OF SEVERE ACUTE HEPATITIS OF UNKNOWN ORIGIN IN CHILDREN Severe acute hepatitis of unknown origin in children was first reported by the United Kingdom to the World Health Organization on April 5,2022.Subsequently,650 probable cases were reported worldwide by May 26,2022,1 and four patients were analyzed after reviewing the clinical records of a children's hospital in Alabama since October 1,2021.2 Although most patients recovered,the disease progressed to acute liver failure in several patients,who further required liver transplantation;thus,additional research is required to determine the disease pathogenesis.