A 7-year-old female child presented with a two day history of nausea and vomiting. Except icterus and a 3 cm soft liver, no other significant clinical findings were present. A clinical diagnosis of viral hepatitis was made. The next day she was hospitalized in view of persistent vomiting and poor intake. On admission, SGPT was 2587 IU/L with serum bilirubin of 8.4 mg/dL (direct 5.5 mg/dL), and prothrombin time was prolonged (18/12 sec). Blood counts were normal and Australia antigen was negative. Serum proteins were normal. Abdominal songography revealed mild hepatomegaly with increased echo-genicity and normal echotexture. Gall bladder was contracted with thick edematous wall. No gall stones were present. Marked ascites was present. Bilateral pleural effusion was also noticed. Chest X-ray also revealed left sided pleural effusion with left lower zone haziness.

We were obviously dealing with viral hepatitis with unusual associated clinical features like cholecystitis, ascites, and pleural effusion. At this point, there was a diagnostic dilemma – whether we were dealing only with infective hepatitis or hepatitis along with another associated illness. The most likely associated diseases could be enteric fever or leptospirosis. These possibilities were ruled out by negative widal, blood culture and leptospira IgM tests. Positive IgM and IgG antibody titers confirmed the diagnosis of Hepatitis A.

Meanwhile, the child improved sympto-matically. Fifteen days after discharge, SGPT and serum bilirubin was normal. USG abdomen showed normal well distended, smooth walled gall bladder. There was no pleural effusion.

Children almost universally recover from HAV infections. Acalculous cholecystitis in association with hepatitis A though rare is a known association as a complication(1). Commonly these patients have an uneventful course. Pleural effusion is a rare complication of acute viral hepatitis. The first case was reported in 1971, and thereafter 14 additional cases were reported. Among those, 5 were associated with hepatitis B and 2 had hepatitis A infection. The exact mechanism is unknown, though immune complexes have been cited as possible etiological factor. Pleural effusion is a possible benign and early complication of acute hepatitis A infection that resolves spontaneously regardless of illness out-come(3). Ascites is also a known complication of Hepatitis A(3). A search of the literature did not reveal any single case with all three complications simultaneously. However none of these features are markers of serious illness, and tend to resolve spontaneously.

Prakash Vaidya,
Chitra Kadam,
Child Health Clinic,
104/B Ambika Plaza,
90 Ft. Road, Mulund (East),
Mumbai 400 081, India.

1. Casha P, Rifflet H, Renou C, Bulgare JC, Fieschi JB. Acalculous acute cholecystitis and viral hepatitis A. Ann Intern Med 1994; 120: 398-400.

2. Emre A, Dincer Y, Hancer Y, Aksaray N. Pleural effusion associated with acute hepatitis A infection. Ped Inf Dis 1999; 18: 1111-1112.

3. Gurkan F. Ascites and pleural effusion accompanying hepatitis A infection in a child. Clin Microbiology Infect 2000; 6: 286-287.