Both systemic and local infections caused by bacterial, fungal, and parasitic agents may cause significant hepatic dysfunction. This chapter attempts to delineate clinical syndromes caused by some of these organisms in the pediatric patient.

BACTERIAL INFECTIONS

Hyperbilirubinemia Associated with Sepsis

Although jaundice in association with bacterial sepsis may occur in adult patients, it appears to be significantly more common during infancy. Historically, infections of the urinary tract predominate; however, sepsis originating from other sites may contribute [1–4]. Accordingly, gram-negative bacilli, and especially Escherichia coli, are responsible for the majority of cases, although gram-positive organisms have been associated. Abnormal liver chemistries are found in approximately 50% of premature neonates with gram-negative bacteremia [5]. Clinical and laboratory manifestations are primarily those of the underlying disease state. Hyperbilirubinemia may be marked, with the direct fraction predominant [1]. Alkaline phosphatase levels are often elevated, and serum aminotransferase values remain normal or minimally increased [6, 7]. Hepatic biopsy usually demonstrates canalicular cholestasis, with minimal evidence of hepatocyte damage or inflammatory response [6] (Figure 37.1). On occasion, the biopsy may demonstrate prominent acute cholangitis with portal bile ductular proliferation, pathologic changes often seen in large bile duct obstruction. In these cases, the possibility of large duct obstruction must be excluded by ultrasound or endoscopic retrograde cholangiopancreatography (ERCP). Jaundice resolves with appropriate treatment of the underlying infection; duration of jaundice may vary from several days to several weeks.