To the Editor: Hepatitis A virus (HAV) infection typically causes a self-limiting inflammatory disease of the liver, although it can sometimes lead to complications including acute liver failure (ALF), prolonged cholestatic hepatitis, hemolysis, secondary Hemophagocytic lymphohistiocytosis (HLH), acute kidney injury (AKI) and acute pancreatitis [1]. We report an atypical presentation of HAV infection in an infant.

A 2 mo 10 d old female infant was admitted with loose stools, vomiting along with high-grade fever and subsequently developed lethargy, refusal to feed and anuria. History of occasional cow milk and water ingestion was present. The baby had features of shock along with tachypnea, hypoxemia on room air (SpO2 - 65%) and hepatomegaly. She was resuscitated with intravenous fluids and managed with empirical antibiotics and oxygen therapy. Investigations revealed leukocytosis (total leucocyte count 20000/mm3; P57L41). Sepsis work up was negative. Serum urea and creatinine were raised. Electrolytes were normal. She also had features of liver failure - markedly elevated transaminases, hypoalbuminemia and deranged International Normalized Ratio (INR). Viral markers for Hepatitis B and Hepatitis C were negative, however IgM was positive for HAV. She was continued on supportive treatment and was discharged on day 9 on exclusive breast feeds with complete recovery of liver and renal functions.

Hepatitis A virus is the most common infectious cause of acute hepatitis. AKI is a rare complication of ALF. The simultaneous onset as well as recovery of both AKI and ALF suggests a common pathogenic mechanism affecting renal tubular cells and hepatocytes [2]. The suggested mechanism for AKI are: Alteration of renal hemodynamics by circulating immune complexes/endotoxins or due to hyperbilirubinemia and bile salts, cytopathic effect of HAV on renal tubular cells and hypovolemia due to fever, anorexia and vomiting [2,3,4]. Our case is atypical since HAV infection is unusual in infants and has not been documented in the past.