Symptoms of hepatitis B in children

In typical cases of hepatitis B, four periods are distinguished: incubation, initial (pre-icteric), peak period (icteric) and convalescence.

The incubation period of hepatitis B lasts 60-180 days, most often 2-4 months, in rare cases it is shortened to 30-45 days or extended to 225 days. The duration of the incubation period depends on the infective dose and the age of the children. In case of massive infection (blood or plasma transfusions), the incubation period is short - 1.5-2 months, and in case of parenteral manipulations (subcutaneous and intramuscular injections) and especially in case of household infection, the duration of the incubation period is 4-6 months. In children of the first months of life, the incubation period is usually shorter (92.8 ± 1.6 days) than in children of older age groups (117.8 ± 2.6 days).

Clinical manifestations of the disease are completely absent during this period, but, as with hepatitis A, at the end of incubation, the blood is characterized by a constantly high activity of liver cell enzymes and the detection of markers of an active infection: HBsAg, HBeAg, anti-HBcIgM.

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Initial (pre-icteric) period

Hepatitis B in children often (65%) begins gradually. An increase in body temperature is not always noted (40%) and usually not on the first day of the disease. The patient may experience lethargy, weakness, increased fatigue, and loss of appetite. Often these symptoms are so weak that they are overlooked, and the disease seems to begin with darkening of the urine and the appearance of discolored feces. In rare cases, the initial symptoms are sharply expressed: nausea, repeated vomiting, dizziness, drowsiness. Dyspeptic disorders often occur: decreased appetite up to anorexia, aversion to food, nausea, vomiting, flatulence, constipation, and less often diarrhea. Older children complain of dull pain in the abdomen. During examination in this period, general asthenia, anorexia, enlargement, hardening and soreness of the liver, as well as darkening of the urine and often discoloration of the feces can be detected.

Muscle and joint pain, which is often found in adult patients, is very rare in children in the pre-icteric period.

Rarely, in the pre-icteric period, skin rashes, flatulence, and bowel disorders are observed.

Catarrhal symptoms are not at all characteristic of hepatitis B.

The most objective symptoms in the initial period are enlargement, hardening and pain of the liver.

Changes in peripheral blood in the initial period of hepatitis B are not typical. Only slight leukocytosis, a tendency to lymphocytosis can be noted; ESR is always within normal limits.

In all patients, already in the pre-icteric period, high activity of ALT, AST and other hepatocellular enzymes is detected in the blood serum; at the end of this period, the content of conjugated bilirubin in the blood increases, but the indicators of sedimentary tests, as a rule, do not change, there is no dysproteinemia. HBsAg, HBcAg, anti-HBcIgM circulate in high concentrations in the blood, and viral DNA is often detected.

The duration of the initial (pre-icteric) period can range from several hours to 2-3 weeks; on average, 5 days.

Jaundice period (peak of the disease)

1-2 days before the onset of jaundice, patients experience darkening of urine and, in most cases, discoloration of feces. Unlike hepatitis A, in hepatitis B the transition of the disease to the third, icteric period in most cases is not accompanied by an improvement in the general condition. On the contrary, in many children the symptoms of intoxication increase.

Jaundice increases gradually, usually within 5-7 days, sometimes 2 weeks or longer. Jaundice can vary from light yellow, canary or lemon to greenish-yellow or ocher-yellow, saffron. The severity and shade of jaundice are associated with the severity of the disease and the development of cholestasis syndrome.

Having reached its peak severity, jaundice in hepatitis B usually stabilizes within 5-10 days, and only after that does it begin to decrease.

A rare symptom of hepatitis B in children can be considered a rash on the skin. The rash is located symmetrically on the limbs, buttocks and trunk, can be maculopapular, red in color, up to 2 mm in diameter. When squeezed, the rash takes on an ocher color, after a few days, slight peeling appears in the center of the papules. These rashes should be interpreted as Gianotti-Crosti syndrome, described by Italian authors for hepatitis B.

In severe forms, at the height of the disease, manifestations of hemorrhagic syndrome are possible: pinpoint or more significant hemorrhages into the skin.

In parallel with the increase in jaundice in hepatitis B, the liver enlarges, its edge thickens, and pain occurs upon palpation.

Enlargement of the spleen is observed less frequently than enlargement of the liver. The spleen is often enlarged in more severe cases and during a long course of the disease. Enlargement of the spleen is noted throughout the acute period with slow reverse dynamics. Often the spleen is palpated even after the disappearance of other symptoms (except for liver enlargement), which, as a rule, indicates a protracted or chronic course of the disease.

In peripheral blood at the height of jaundice, the number of erythrocytes tends to decrease. In severe forms, anemia develops. In rare cases, more severe changes in the bone marrow are possible, up to the development of panmyelophthisis.

During the icteric period, the number of leukocytes is normal or decreased. In the leukocyte formula at the height of toxicosis, a tendency to neutrophilia is revealed, and during the recovery period - to lymphocytosis. ESR is usually within normal limits. Low ESR (1-2 mm/h) with severe intoxication in a patient with a severe form of hepatitis B serves as an unfavorable sign.

Convalescent, recovery period

The total duration of the icteric period in hepatitis B ranges from 7-10 days to 1.5-2 months. With the disappearance of jaundice, children no longer complain, they are active, their appetite is restored, but half of the patients still have hepatomegaly, and 2/3 have minor hyperfermentemia. The thymol test may be elevated, dysproteinemia is possible, etc.

In the convalescent period, HBsAg and especially HBeAg are usually no longer detected in the blood serum, but anti-HBe, anti-HBc IgG and often anti-HBs are always detected.

Malignant form of hepatitis B in children

The malignant form occurs almost exclusively in children of the first year of life. Clinical manifestations of malignant forms depend on the prevalence of liver necrosis, the rate of its development, and the stage of the pathological process. A distinction is made between the initial period of the disease, or the period of precursors, the period of development of massive liver necrosis, which usually corresponds to the state of precoma and rapidly progressing decompensation of liver functions, clinically manifested by coma I and coma II.

The disease often begins acutely: body temperature rises to 38-39 °C, lethargy, adynamia, sometimes drowsiness appear, followed by attacks of anxiety or motor agitation. Dyspeptic disorders are expressed: nausea, regurgitation, vomiting (often repeated), sometimes diarrhea.

With the appearance of jaundice, the most constant symptoms are: psychomotor agitation, repeated vomiting with blood, tachycardia, rapid toxic breathing, abdominal distension, pronounced hemorrhagic syndrome, increased body temperature and decreased diuresis. Vomiting "coffee grounds", sleep inversion, convulsive syndrome, hyperthermia, tachycardia, rapid toxic breathing, liver odor from the mouth, and a decrease in the liver are observed only in malignant forms of the disease. Following these symptoms or simultaneously with them, there is a clouding of consciousness with clinical symptoms of hepatic coma.

Among the biochemical indicators, the most informative are:

• bilirubin-protein dissociation - with a high content of bilirubin in the blood serum, the level of protein complexes decreases sharply;
• bilirubin-enzyme dissociation - with high bilirubin content, a decrease in the activity of hepatic cellular enzymes is observed, as well as a decrease in the level of blood clotting factors.