Hepatitis A with Superadded Salmonella paratyphi A Infection Presenting with Exudative Pleural Effusion and Acalculous Cholecystitis

Correspondence

Indian Pediatr 2017;54: 514-515

Hepatitis A with Superadded Salmonella paratyphi A Infection Presenting with Exudative Pleural Effusion and Acalculous Cholecystitis

*Aniruddha Ghosh and Pavel Kundu

Department of Pediatric Medicine, Institute of Child Health, Kolkata, India.
Email: [email protected]

Both hepatitis A and enteric fever are major public health problems in developing countries [1,2]. Transudative pleural effusion and ascites have been reported in hepatitis A but rare in enteric fever [3-5].

A 4-year-old girl presented to us with fever for 15 days along with jaundice, cough and dyspnea. Since day-8 of fever, child had multiple petechial rashes all over the body. There was no history of blood transfusion, intravenous drug use, tick bite, or contact with tuberculosis. There was no history of MMR, Hepatitis A, Hepatitis B or Typhoid vaccination. Chest examination revealed stony dull percussion note anteriorly over right side of chest starting from 2nd intercostal space downwards in mid clavicular line with absent breath sounds. Abdomen was distended, and there was tender hepatomegaly and mild splenogmegaly. Other system examination was normal.

Investigation showed anemia (Hb 8.3 g/dL), elevated C-reative protein (36.1 mg/L), and deranged liver function tests (total bilirubin 5.6 mg/dL, direct bilirubin 5.5 mg/dL, alanine aminotransferase 366 U/L, aspartate aminotransferase 256 U/L, gamma glutamyl transferase- 359 U/L, Alkaline phosphatase 787 U/L); child also had coagulopathy (INR = 1.92).

Fig.1 Magnetic resonance imaging coronal view showing massive right sided pleural effusion and hyperintensity in gall bladder area with thickened wall (arrow) indicative of acalculous cholecystitis.

Chest radiograph revealed opacity involving lower and middle zone of right lung with a sharp convex upper border without mediastinal shift. MRI of chest and abdomen (Fig. 1) showed massive pleural effusion with collapsed lobes of right lung, hepatosplenomegaly and hyperintense gall bladder with thickened wall suggestive of acalculous cholecystitis. IgM for Hepatitis A was reactive. Tests for other hepatotropic organisms and tuberculosis yielded negative results. Intravenous vitamin K was administered. A diagnostic pleurocentesis revealed exudative pleural effusion; culture did not reveal any growth. Widal test was positive ((T(O) 1:160, A(H)-1:320)) and blood culture demonstrated Salmonella paratyphi A. Intravenous cefotaxime (200 mg/kg/day) was administered, and after 3 days, the patient became afebrile; distress also decreased considerably and before discharge, repeat LFT showed improvement. Child was discharged with oral cefixime (20 mg/kg/day). Chest X-ray showed clearance of fluid during one week follow-up. The patient was doing well after a follow-up of two months.

Exudative pleural effusion in viral hepatitis should be investigated to rule out other coinfections.

References

1. Hunter PR, MacDonald AM, Carter RC. Water supply and health.　PLoS Med.　2010;7:e1000361.

2. Prüss A, Kay D, Fewtrell L, Bartram J. Estimating the burden of disease from water, sanitation, and hygiene at a global level.　Environ Health Perspect.　2002;110:537-42.

3. Tesovic G, Vukelic D, Vukovic B, Benic B, Bozinovic D. Pleural effusion associated with acute hepatitis A infection. Pediatr Infect Dis J. 2000;19:585-6.

4. Erdem E, Urgancý N, Ceylan Y, Kara N, Ozcelik G, Gulec SG. Hepatitis A with pleural effusion, ascites and acalculous cholecystitis.　Iran J Pediatr. 2010;20:479-82.

5. Huang DB, DuPont HL. Problem pathogens: Extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis. 2005;5:341-8.