LTF Yeung, M Fearon¹, EA Roberts

Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto; ¹Laboratories Branch, Ontario Ministry of Health & Long-term Care, Ontario, Canada

Chronic hepatitis C (CHC) is the most common indication for liver transplantation in adults since it may cause cirrhosis and hepatocellular carcinoma. In children, the prevailing impression is that paediatric CHC is largely asymptomatic and slowly progressive. Yet some children with CHC have cirrhosis, and a few have required liver transplantation. As the cases of transfusional hepatitis C diminish over time, the proportion of paediatric C-A CHC (infection by vertical, intrafamilial, or unknown routes) will predominate. The natural history of paediatric C-A CHC is poorly understood. The rate of vertically-transmitted hepatitis C virus (HCV) remains disputed, whether C-A CHC resolves spontaneously in childhood is unknown, and predictors of severe disease are not known.  This study represents our first attempt to address these questions.  

We report a prospective, consecutive series of 34 non-transfused children positive for serum anti-HCV, indicating community-acquired HCV exposure or infection. Anti-HCV was transmitted vertically in 31 of 34 cases. Follow-up lasted 0.5-6.2 yrs until 1-13.6 yrs of age; 16 were male. Chronic hepatitis defined by persistently elevated serum ALT, positive anti-HCV and detectable HCV RNA, (by RT-PCR: Amplicor, Roche) was present in 8 (24%) cases. One of these had liver biopsy at 2 yrs of age showing portal inflammation only. Anti-HCV was lost in 23 (68%) cases: one girl appeared to clear a hepatitis C infection; her biopsy at 9 mos found slight portal infiltrates consistent with chronic hepatitis C. Anti-HCV was also lost by two older children with normal ALT and negative HCV RNA. 20 of 23 (59%) lost anti-HCV before 18 mos of age, likely representing passive transfer of maternal antibody and not infection. In a further 3 (9%) cases anti-HCV persisted without HCV RNA, over a 2-6 yr period.

Conclusion: This is the first published Canadian series of C-A CHC in children.  In our experience, determining the exact source of infection and predicting the outcome of C-A CHC in early childhood is difficult. Vertical transmission of HCV is uncommon. Persistence of detectable HCV RNA in children >5 yrs-old indicates development of CHC.  So far, all children with C-A CHC appear to have mild liver disease. Clearance of antibody in cases of C-A HCV infection may rarely occur, representing spontaneous recovery from HCV infection in childhood.

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