Four-year- and eight-month-old, previously well, male child presented with abdominal pain, loss of appetite, low-grade intermittent fever, nausea, vomiting, and progressive abdominal distension of ten days duration. He has also cough of five days duration. There was no history of yellowish discoloration of eye or skin, bleeding or previous history of jaundice, urinary complaints, and change in urine or stool color. He has no history of contact with chronic cougher or with tuberculosis-diagnosed patients.
On examination: Blood pressure 90/60mm, pulse rate 88/minute, respiratory rate 20/minute, and temperature 37 C. There was decreased air entry and dullness in the lower lung field bilaterally. Distended abdomen, fluid shift was positive; the liver was palpable 6cm below the right costal margin, total liver span 11 cm, and tender. There was some palmar pallor, otherwise normal.
On investigations, hepatitis A antibody immunoglobulin M was reactive, with a titer of >10.11. Other viral markers (hepatitis B, hepatitis C, and human immunodeficiency virus test was negative). Echocardiography study was normal. Other investigations are listed in Table 1.  
Ultrasonography examination revealed minimal ascites, hepatosplenomegaly, and small bilateral pleural effusion. Ultrasound guided-pleural tap revealed no cells, lactic acid dehydrogenase 15 IU/L, gene Xpert for tuberculosis was negative and bacteriologic culture was negative. Gastric aspirate was also done for gene Xpert and found to be negative.
Based on those investigations, the diagnosis of anicteric acute viral hepatitis A with unusual manifestations of pleural effusion and ascites was made. He was managed with supportive treatment (hydration, rest, antiemetics, a well-balanced diet). The liver enzymes were corrected within two weeks, ascites and pleural effusion disappeared after two weeks. Liver and spleen sizes were normalized after one month of follow-up.