In May of 2020 I talked about a rare inflammatory condition that had only been diagnosed in a few hundred children around the world. The Multisystem Inflammation Syndrome in Children (MIS-C) was linked to prior infections with the SARS-CoV-2 virus. In the United States alone, almost 8,000 children have been diagnosed with MIS-C, and there have been 66 deaths.
The cases of COVID-19 that eventually result in MIS-C tend to be mild or even asymptomatic, a fact that is often ignored by people downplaying the potential harms of infection in young children. It also occurs in a random pattern, meaning that any child who is exposed to the disease is at risk. Death is not the only cause of concern for kids, who are also at risk of life-threatening symptoms related to long-haul COVID.
Last week, the CDC issued a health advisory via the CDC Health Alert Network to inform clinicians and public health authorities of a cluster of children with severe inflammation of the liver, some of which required a transplant. They warned of a possible link to a viral infection, though it doesn't seem to be the case this time around. The most likely culprit is an adenoviruses.
Several children in a New Jersey nursing home died from severe respiratory disease during an outbreak of adenoviruses, and I wrote about it. I talked about the fact that a vaccine that has historically only been available for military use but reasonably could be used in a focused manner in high risk populations should be used in a focused manner in high risk populations. Please check out that post for more information on this fascinating family of viruses.
Adenoviruses can cause disease throughout the human lifespan, even though they are known to cause febrile illnesses in children. Upper respiratory infections are usually the cause of the common cold. There are seven species of adenoviruses that cause humans to contract them, with more than 60 different types, and they are to blame for a variety of clinical presentations. Adenoviruses can also cause upper and lower respiratory infections, as well as encephalitis andhemorrhagic cystitis. They can cause disease, which means that the virus gets all over the place.
The specific clinical presentations seen with various adenoviruses can provide clues as to the specific type involved. The combination of sore throat and pink eye is associated with the Serotypes 3 and 7. 40 and 41 cause a lot of problems. Respiratory symptoms can be caused by many different types of infections. Most adenoviral disease is mild and resolves with simple supportive care, but any type of adenoviral disease can cause severe, atypical, or even fatal disease in someone who can't mount an effective immune response.
Alabama was the first state to report a spike in cases of children being diagnosed with hepatitis. In November of last year, a single hospital reported five children with severe liver injury, three of which would eventually develop liver failure. All five children were found to have an adenoviral infection, but all were negative for COVID-19.
A targeted search led to the discovery of four additional cases, bringing the total to nine children, all young, and previously healthy. There was no epidemiological link or common exposures for these children. Seven of the nine cases were associated with adenoviruses, which is not a known cause of the disease except in patients with a severely compromised immune system. Children who are healthy are affected by adenoviruses 41.
Even in children, it is not an uncommon condition. It's usually caused by a viral infection. The United States used to have a lot of hepatitis caused by the hepatitis A virus, which is easily spread via the fecal-oral route, but has decreased thanks to a childhood vaccine that was added to the schedule in the mid-90s. The causes of inflammation in the body are well known, but not particularly common in children.
Various enteroviruses, parvoviruses, and adenoviruses are possible causes of hepatitis as well. As a hospitalist closing in on twenty years of practice, I have seen several cases of hepatitis which have been mild and associated with the Ebstein-Barr virus, which is more notorious for causing infectious mononucleosis. I've managed one teenage patient with chronic hepatitis B and one child with an auto Immune hepatitis. I have treated a number of patients who INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals INRDeals
Young children are more likely to have severe hepatitis. The CDC alert says that a cluster of nine cases in one hospital over a few months is unusual. This was not the only cluster.
The United States is not the only country that has seen a spike in cases. The number of regions involved quickly grew as the World Health Organization released a similar alert last. In their April 23rd Disease Outbreak News publication, the WHO revealed that at least 169 cases had been reported from 11 countries in the European Region and one Region of the Americas. The United Kingdom and Ireland had the most reported cases.
All 169 cases involved children under the age of 17 years. At least one of these patients had died and 17 of them ended up needing a transplant. There were at least 74 cases where adenoviruses was detected. There were 20 positive for the disease and 19 positive for it. The WHO says that common viral causes of hepatitis were ruled out in each case and that no particular risk factors were identified.
There have been more cases reported in other states since last week. The first death related to this condition in the United States is thought to have occurred in Wisconsin. There have been cases reported in North Carolina. Canada and Japan have joined the list of countries reporting possible cases. There is good reason to worry that this is just the beginning, but cases are still very rare.
It's understandable to try to link the SARS-CoV-2 Pandemic to other unusual outcomes, and a surprising cluster of severe liver disease in kids, with everything that has happened over the past two years. The leading hypothesis so far is adenoviruses. The United Kingdom has seen a significant increase in community adenoviruses and detection in waste water compared to 2020. It's not likely that this is a coincidence.
Children that are healthy should not be at risk of being caused by adenoviruses like this. What is it that gives? Increased caution, masks, and school closings have largely spared children from adenoviruses over the past two years. There is a chance of seeing very rare potential problems with larger numbers of kids.
There is a chance that a genetic change in adenoviruses may have increased its virulence or that it is causing atypical disease. It is clear that this is not a side effect of the vaccine because most of the cases have been seen in children too young to have received one. We need to keep an open mind to a possible cause that nobody has even thought of yet, and we need more data from detailed investigation into these and additional cases that pop up as surveillance increases.
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