A Rare Association of Hydrops of Gall Bladder with Hepatitis E Infection

Gall bladder distension with acute viral acalculous cholecystitis is an extremely rare event especially with Hepatitis E infection in paediatric cases with a high incidence of perforation, gallbladder necrosis and mortality. We report a four year old male child presenting with fever, vomiting, pain abdomen, mild hepatosplenomegaly and tenderness in right hypochondrium. Laboratory investigations revealed hyperbilirubinemia and elevated liver enzymes, but there was no evidence of bacterial or parasitic infection. Serology for viral hepatitis suggested acute Hepatitis E infection. Ultrasonographically distended inflamed gallbladder without calculous was observed. Finally acute acalculous cholecystitis due to Hepatitis E virus was diagnosed and the child responded to the conservative management.


Introduction
Acute hepatitis E virus (HEV) infection is frequently encountered in deve loping countries especially in children 1 .Extra-hepatic manifestations of hepatitis virus include arthalgias, cutaneous vasculitis, cryoglobulinemia, and hemophagocytic syndrome.These manifestations are rare; when they do occur, they resolve with the resolution of hepatitis 2 .
During HEV infection, the gallbladder changes have never been reported in available literature.The gall bladder may undergo changes that include decreased fasting volume, increased wall thickening and appearance of biliary sludge 3 .Gallbladder involvement has been described in 50 to 98% of adults with acute viral hepatitis (especially hepatitis A), mild gallbladder wall thickening (GBWT) being the most common sonographic fi nding 4 .
Here we report a four years old male child with acute hydrops of gall bladder due to hepatitis E virus infection.

Case report
A four years old male child presented to us with the complaints of fever, fatigue, nausea, vomiting, abdominal pain and loss of ap petite of seven days duration.In the last three days, mother noticed that he was having dark urine and yellowish discolouration of eyes.There was no signifi cant past medical history.There was no history of medication in recent past.
The child was started on injectable antibiotics and IV fl uids.Within seven days of admission to the hospital, his jaun dice, abdominal pain, vomiting frequency, temperature, skin icterus and abdominal tenderness decreased.The right side of the abdomen was less tender.Repeat ed biochemical study showed total bilirubin 2.9 mg/dL, with a direct fraction of 1,8 mg/dL, ALT: 1025 U/L and AST: 1233 U/L and alkaline phosphates: 974 U/L (38-155 U/L).Abdominal ultrasound revealed hepato megaly, and reduced size of gall bladder compared to earlier report.Presently the child is afebrile and doing well.He was discharged on the 10th day of admission in good clinical condition and with considerable improve ment in biochemical tests He is kept under follow up in our OPD.
Early studies have shown that during viral hepatitis, the gallbladder may undergo changes that include decreased fasting volume, increased wall thickening and appearance of biliary sludge.These morphofunctional events are transient and gradually disappear when viremia becomes low.Gallbladder wall thickness returns to normal in these patients within few days.These patients do not require surgical intervention.
There is no case report of Hepatitis E with hydrops of gall bladder in children.Only few cases of gallbladder involvement during HAV infection were reported in medical literature 5 .The exact reason for the involvement of gall bladder with hepatitis E infection requires further research.It should be kept in mind that although rare, acute viral cho lecystitis can develop during the course of acute HEV infec tion in children 6 .We suggest that the right upper quadrant pain, high temperature, severe vomiting, severe jaundice during acute hepatitis E is, at least in part, may be caused by gallbladder involvement.Paediatricians and paediatric surgeons must be familiar with the possibility of gallblad der and pancreatic involvement during HEV infection to avoid unnecessary invasive procedures.

Discussion
Hepatitis E virus is a self-limiting, usually asymptomat ic infection that occurs predominantly among children.It is generally catastrophic in pregnant females.In some patients, gallbladder abnormalities such as increased thickness of the gallbladder wall and sludge formation were described.These chil dren presenting with acute hepatitis had an initial clinical onset suggestive of acute cholecystitis (pain and guarding in the right hypochondrium, fever and delayed jaundice) associated with important ultrasonographic fi ndings including: increased gallbladder wall thickness and rarely hydrops of gall bladder.