Atypical presentation of pediatric acute hepatitis A: Is the situation alarming?

Table 1 Atypical pediatric hepatitis A virus manifestations

Presentation	Key features	First-line tests	Initial management	When to escalate
Prolonged cholestasis	Jaundice > 12 weeks, pruritus, pale stools	LFTs, GGT, USG	UDCA ± rifampicin, vitamins A-D-E-K	Rising INR > 1.5 or bilirubin ↑ > 3 months
Relapsing HAV	Recurrence 4-15 weeks after recovery	LFT, HAV PCR	Supportive, monitor	Persistent > 3 months → exclude AIH/DILI
Autoimmune-triggered	Prolonged hepatitis, ANA/ASMA+, high IgG	Autoantibody panel, IgG	Immunosuppression (AIH protocol)	Liver failure or biopsy AIH pattern
Hemolysis (G6PD)	Anemia, dark urine	CBC, LDH, reticulocyte, G6PD	Hydration, avoid oxidants	AKI → dialysis
Ascites/effusions	Abdominal distension	Ultrasound, albumin	Sodium restriction ± diuretics	Non-resolving > 8 weeks
Neurologic/pancreatitis	Confusion or epigastric pain	LFTs, amylase/Lipase	Supportive	Persistent deficits

HAV: Hepatitis A virus; LFT: Liver function test; GGT: Gamma-glutamyl transferase; USG: Ultrasonography; UDCA: Ursodeoxycholic acid; PCR: Polymerase chain reaction; ANA: Anti-nuclear antibody; ASMA: Anti-smooth muscle antibody; IgG: Immunoglobulin G; AIH: Autoimmune hepatitis; CBC: Complete blood count; LDH: Lactate dehydrogenase; INR: International normalization ratio; DILI: Drug-induced liver injury; AKI: Acute kidney injury.