General status of virus hepatitis
Virus hepatitis is a very common infections disease, existing widely in all races of human beings. Hong Kong, China and the countries in Southeast Asia are districts with high incidences of virus hepatitis. In the past, it was considered that only virus causing clinical manifestations of hepatitis can be defined as hepatitis virus, which, at the present time, is classified into 7 types. But now, it is identified that, besides hepatitis virus, parotitis virus, simple herpes virus, cytomegalovirus, EB virus, Coxsackie virus, ECHO virus, yellow fever disease virus, German measles virus all can cause pathological changes of chronic virus hepatitis in the infected children, although they have their respective clinical characteristics. These viruses are called in general “hepatophilic virus”, although they do not belong to the hepatitis group. When the child is infected by hepatophilic virus and develops chronic virus hepatitis, he would display the symptoms of TCM classified forms of chronic hepatitis as well as the sign of hepatomegaly. Cessation of advance of disease and the damage produced can be accomplished only by the administration of systemic TCM therapy. Therefore, if the diagnosis of chronic hepatitis is confined to the conventional standard, it is very likely that one may drop into the pitfall of misdiagnosis or may miss the diagnosis altogether.
The spread of virus is highly infectious as well as regional. In virus hepatitis, the B and C types draw most of the attention of human beings because, according to statistics, in the 300 million type B hepatitis virus carriers throughout the world, two thirds are located in Asia. Recent reports revealed that the majority of HBV infected patients in China had their infection initiated at infancy, especially through mother-child communication. Patients infected during infancy have a 90% possibility of developing chronic hepatitis in which 40% may aggravate to form cirrhosis of liver. In adult infected individuals, only 5% advance into chronic type B hepatitis, in which 5%-20% may develop cirrhosis of liver. So, the prevention and treatment of virus hepatitis should not be neglected, especially when the infection occurs during infancy because the harm done is more serious.
Hepatophilic virus diseases, like chronic type B hepatitis, are atypical or latent diseases. The patient’s early symptoms are usually mild, easy to be neglected and the diagnosis and treatment may be delayed. If found at the time when clinical symptoms are obvious, or at the stage of cirrhosis or carcinoma of liver, the optimal time for treatment is lost. Therefore, further understanding of the characteristics of pediatric chronic hepatitis and its early diagnosis and treatment are very important. In this way, malnutrition, underdevelopment and symptoms of different systems induced by chronic hepatitis may be prevented; and also this is one of the critical measures in the prevention of cirrhosis or carcinoma of liver in the subsequent adult years.
Initial virus hepatitis infection often occurs at infancy and childhood
In the present studies on virus hepatitis, type B hepatitis is commonly used as the chief object of investigation. Infancy and childhood are the prevailing years of type A and B hepatitis, especially type B hepatitis, in which spread through mother-child communication is extremely common. The dissemination of type C hepatitis is also achieved through mother-child communication as well as close contact. Type E hepatitis is comparatively less in children, and most of these cases belong to the sub-clinical type of infection and may be easily neglected by the patient and doctor. From the above data, it is shown that the majority of virus hepatitis infections occur during infancy or childhood. According to statistics in China, we can also find that damage from various types of viral infections hepatitis to infants and children is not only very common but also very serious.
In pediatric liver diseases, virus hepatitis B accounts for 75. 4%. According to data from Disease Prevention and Control Centre in mainland, 42% adult chronic hepatitis B patients were infected during childhood. The incidence of infection at birth is 40% in male and 20% in female. Advance of disease into cirrhosis and carcinoma of liver is closely related to HBV. Some reports revealed that in our country and Southeast Asia countries, infection by hepatitis B virus during infancy, childhood and adolescence, often times progressed into a chronic condition, persisting for years, over ten years or even for a life time. 70%-90% of these patients are prolonged “antigen carriers”, but they may show no significant symptoms. Their liver functions are normal, but 90% of liver biopsies reveal tissue damage. In the past, it was considered that pediatric hepatitis B pathological changes were mild and hepatitis remained in the guiescent condition which did not require treatment. This viewpoint may not be correct. In fact, the liver function (ALT) changes of pediatric hepatitis B patients often times are not consistent with tissue pathology due to disturbance of immune tolerance or immune function, so one should not wait for the occurrence of abnormal results of blood examination and ultrasound scan to start treatment. It is, therefore, advisable to make every effort to obtain early diagnosis and give early treatment according to the special features of pediatric liver disease.
Presently, large amounts of clinical study have revealed that chronic virus hepatitis is not caused by hepatitis virus alone and that virus has multiple characteristics, especially when it infects the host. It can produce a persistent virus infection which becomes the source of many common and frequently encountered diseases that may play an important role in causing failure of multiple systems of the body and in senility and death of human beings. In fact, human life is a life concurrent with virus as well as a life never ending in the struggle against virus. Not a few reports have demonstrated that virus infection may have attacked the fetus in the course of intrauterine development. For example:German measles virus infection may occur in early pregnancy, causing intrauterine infection which can induce abortion, mal-development and congenital anomaly. Cytomegalovirus infection also exists widely in the world, especially in developing countries, and in our country, the compliment – antibody test positive rate is 72.6%-76.84% in pregnant women, indicating that cytomegalovirus infection in adult females is rather high in which 1/4 may be primary infections. It endangers the fetus to develop into monsters, to be dead and aborted or acquire icterus neonatorum. Despite of successful pregnancy and delivery, some infants, within 3 months after birth, may develop purpura, hepatitis, encephalitis and pneumonia. Other viruses such as the human parvovirus, hepatitis virus, AIDS virus, simple herpes virus, cytomegalovirus and EB virus can permeate through the placenta and infect the fetus. Therefore, many primary virus infections occur at the important intrauterine, intra-vaginal, perinatal and infantile stages.
Popularity of virus infection in the world
From review of statistical data, we have an impression of the popularity of virus infection in the world; for example, in infantile stage, high susceptibility to respiratory syncytial virus (under one year old), adenovirus (7-24 months), human herpes virus type 6 (in America, England, Japan infants 6 months to 1 year anti HHV-6 nearly 100% positive). These reveal the direct cause of visceral pathological changes induced by virus infection in infants and it also reveals the unavoidable evidence of being infected by virus in human beings. So, an effective method for the improvement of human body constitution is to give more attention to the diagnosis and treatment of infantile diseases caused by virus, with the hope of decreasing the incidence of many frequently encountered diseases which are the result of liver function damage from viral infections.
Chronic virus hepatitis usually has its initial attack at the newborn stage or during infancy or childhood and its symptoms may be manifested later in the adult stage or when there is hepatic dysfunction as revealed by blood examination. But part of these cases might have already developed chronic hepatitis or even cirrhosis or carcinoma of liver. This may explain the tendency of seeing more and more younger cases of carcinoma of liver. It can be seen that hepatophilic viruses (including all types of hepatitis virus) affect greatly the health and development of children who have no ability to control the infection and even some are infected inside the uterus and doomed to carry the infection throughout life. It is regretful that many parents and clinical physicians do not pay enough attention on pediatric virus hepatitis; they may miss the diagnosis or make the wrong diagnosis, so that the optimal time of treatment slips away. How to discover early the children’s hepatitis is a question that all parents should concern eagerly.
The variability of clinical symptoms of pediatric liver disease: they have decisive effect on the child’s development and grown-up constitution.
Is pediatric virus hepatitis asymptomatic?
This concept is certainly wrong. In fact, when the human body is infected by virus, his immune system produces antibodies against the virus antigen; the antibodies neutralize and eliminate antigens. But during the course of immunologic response, the infected liver cells are also damaged, producing characteristic symptoms of hepatitis. The antigen-antibody complex substances deposit on other tissues of the body, causing simultaneous pathologic changes of extra-hepatic tissues and comparatively serious and persistent injury of other organs. The various clinical symptoms evoked are not characteristic and, so, are often neglected by physicians. Most clinical doctors do not pay attention to the fact that hepatophilic virus is actually the source of these diseases. For example, some auto-immune diseases are associated with arthritis, skin eruptions (pediatric eczema), glomerulonephritis, chronic thyroiditis and xeroderma. These are also some clinically mild symptoms such as nasal hypersensitivity, German measles, upper respiratory catarrh (common cold), gastroeuteritis (abdominal pain, diarrhea), peptic ulcer, biliary tract diseases, intestinal hypersensitivity, anemia, insomnia, long term headache, migraine, extreme tiredness, acne, oral ulcers, malnutrition and underdevelopment and menstrual disorders. If these patients are found in blood examination to have positive antigen and antibody, they may be considered as chronic asymptomatic hepatitis at the most.
In fact, these unnoticed symptoms may be the symptoms produced by frequent replication of hepatitis virus. It is considered by some that in virus hepatitis, the pathological changes inside the liver is pathogeneticallly not similar to those of the extra-hepatic. The intra-hepatic pathologic changes are caused by cellular immune response while the extra-hepatic is chiefly due to immunocomplex. So, clinically, the two pathological changes are not unanimous but contrarily they often show diversity. It is only when one is familiar with the clinical symptoms manifested in different stages of pediatric liver disease as classified by TCM forms, that it is possible to ascertain the diagnosis early and treat the patient early.
By WONG Kwok Hung
translated by Professor ZHENG Hua En in July 2005