Atypical Hepatitis A: Insights into rare clinical outcomes

Background: Hepatitis A virus (HAV) infection is self-limiting with spontaneous remission in 90% of cases. Atypical manifestations occur in a subset of patients. Aims and Objectives: The study was designed to evaluate the clinical presentation, biochemical profile, concomitant drug-induced liver injury (DILI), response to steroids, and severe outcomes in patients with acute viral hepatitis A. Materials and Methods: This prospective observational study included 105 HAV patients aged 8–45 years at a tertiary care hospital in North India. Clinical, biochemical, serological, and autoimmune parameters were assessed. Patients were monitored for atypical manifestations such as the presence of prolonged cholestasis (>4 weeks), autoimmune features, DILI, and extrahepatic involvement. Steroid response and severe outcomes were analyzed. Statistical analysis was performed using the Statistical Package for the Social Sciences. Results: In 105 patients, the mean age was 26.5 years. 18% fell in the pediatric age group (<18 years). 90% had bilirubin levels between 10 and 20 mg/dL, and 10% exceeding >20 mg/dL. Transaminases ranged from 300 to 4000 U/L (mean, 2150 U/L). Cholestatic injury occurred in 80% of patients. DILI in 5% and autoimmune features in 5.7%. Sixty patients received steroids, all showing significant clinical and biochemical improvement (P≤0.05). No extrahepatic manifestations were noted. Acute liver failure (ALF) was observed in 2.9%. Out of which, one patient recovered after liver transplantation. One recovered with plasma exchange, and one died. Conclusion: HAV infection spectrum ranges from cholestatic injury to severe forms such as acute liver failure (ALF). Early recognition of atypical features and selective steroid use may improve outcomes.