Pediatric Hepatitis of Unknown Origin: Are Viruses to Blame?

Navigating new and especially concerning developments can be challenging in the day and age of the Internet being the foremost platform for receiving up to date information…and misinformation. Navigating emerging evidence and opinions, prioritizing what “voices” hold prominence in your own formation of ideas can be difficult. I need to emphasize, the most reliable sources of information are official sources, those associated with government and institutions of positive reputation. Even if you have personal distaste for the approach or conclusions of these entities or personalities, their base facts are indeed facts, not conflation or cherry picking. Internet literacy is a critical skill set in navigating the most expedient tool of information. These details are particularly important as medical personnel and public health professionals turn their eyes to the developing issue of pediatric patients presenting with acute hepatitis “of unknown origin”.

At the time of this writing, more than 300 cases had been identified across more than 20 countries and at least 5 children have died. None of the cases being investigated have uncovered typical hepatitis viruses. According to a Centers for Disease Control and Prevention (CDC) brief, many of the cases in the United States have found active adenovirus infections. The CDC’s brief also “ruled out” COVID-19 as a cause. In the United Kingdom however, about 20% have uncovered active SARS-CoV-2 (the virus that causes COVID-19) infections. Other potential causes are being investigated as public health officials at the WHO and across are requesting providers share case data with local health departments in order to aggregate sufficient information.

Using the official CDC Director’s Twitter account, Dr. Rachel Walensky shared recently issued guidance to providers. The responses from users claiming a variety of expertise expressed concern at the CDC’s declaration that COVID-19 is not a potential cause for these cases. For these users, and likely parents watching the issue hit various news outlets, the omission of a potential for post-COVID responses seems odd and without an explanation and clarity as to investigative processes taken, doesn’t do a whole lot for repairing already deeply damaged public trust. Indeed, all of the readily available links on the issue from the CDC’s website exclusively point toward adenovirus, undermining the nature of investigative efforts to explore multiple potential causes. In contrast, the UK’s governmental updates outline why the COVID vaccine has been ruled out: most children affected are too young to have received the shots (the CDC’s briefing does not include this statement). The United Kingdom Health Security Agency’s latest update on this issue can be found here.

Part of why COVID is suspected is because of some of the unique features of the virus. A growing body of evidence is finding “pieces” of SARS-CoV-2 in a variety of body tissue, not just the lungs or brain as has been readily covered in other reports. One of the most persistent theories being tossed around includes hepatitis (generally, inflammation of the liver) as an issue of “long COVID” or a type of “post-viral” syndrome as a result of COVID infection. Part of the reason for that leap is SARS-CoV-2 has a special propensity for causing cell-to-cell fusion, resulting in “giant” cells with multiple nuclei and allowing the virus to spread in a body in an unusual fashion, evading the immune system. An additional concern is the issue of SARS-CoV-2 “superantigens” or a pathogen that “hyper-stimulates” immune responses. In one theory, currently being investigated, the super-antigenic effects of a COVID infection are being looked at as to the potential causation of multisystem inflammatory syndrome in children (MIS-C). Indeed, the issue is of such concern researchers have submitted to the Lancet (a leading scientific journal regarding infectious disease) an article urging providers to appropriately test tissue samples beyond blood in order to rule out potential long-lasting but harder to detect impacts of a SARS-CoV-2 infection.

Regardless of particular cause, at this stage, parents concerned about their children’s health should be aware that acute hepatitis tends to present similarly to most gastrointestinal bugs; abdominal pain, fever, vomiting, and nausea are common. Jaundice of the skin and eyes and darkening of urine are very key indicators something severe is occurring and needs immediate medical attention. Parents should contact their child’s provider if their children are expressing concerning symptoms.