the 2010 human influenza a ( h1n1 ) virus pandemic seriously affected many countries , including kuwait . in children ,
respiratory involvement usually occurs with h1n1 ; extra pulmonary problems are not common.1 liver involvement is rare and needs early identification and treatment .
a 9-year - old child was admitted with intermittent low - grade fever , cough , vomiting , and abdominal pain lasting for one week .
he received oral antibiotics ; the fever subsided initially but reappeared after a few days , along with jaundice .
he was previously healthy , with no past history of liver disease . on examination ,
he was alert and oriented , his temperature was 39c , he was icteric , appeared toxic , was sweating , had a respiratory rate of 30 breaths / minute , and had congested tonsils ; a respiratory system exam showed prolonged expiration with expiratory rhonchi .
there were no signs of meningeal irritation , and the rest of his physical examination was unremarkable .
investigations revealed a hemoglobin ( hb ) count of 14.5 g / dl , a total leukocyte count of 3.37  10 , neutrophils 19% , lymphocytes 68% , a platelet count of 255  10 .
urinalysis showed mild urobilinogen and ketones , but a urine culture was sterile after 48 hours of incubation .
mmol / l , alanine amino - transferase was 1763 u / l , aspartate amino - transferase was 1871 units / l , alkaline phosphatase was 246 units / l , and gamma glutamyl transferase was 107 units / l .
g / l , serum ammonia count 74 mmol / l , and serum lactate 2.06 mmol / l .
the patient had normal serum amylase and lipase levels , a negative cold agglutinin test , a normal ultrasound of the abdomen , and a negative chest x - ray .
nasal and throat swabs for h1n1 were positive by a reverse transcription polymerase chain reaction ( pcr ) test .
a hepatitis a , b , and c serological screen was negative , and his serum acetaminophen level was normal .
furthermore , an additional work - up to rule out other causes of fulminant liver failure was performed , including negative blood tests for herpes simplex virus pcr , adenovirus pcr , epstein 
his immunoglobulins ( igg , igm , and iga ) were within normal limits ; he also had a negative antinuclear antibody ( ana ) < 1:40 titer and a negative anti - smooth muscle antibody and anti - liver  kidney microsomal antibody ( anti - lkm ) , ruling out the possibility of autoimmune hepatitis . finally , his serum amino acid and urine organic acids were unremarkable .
he was treated according to centers for disease control and prevention ( cdc ) guidelines2,3 with tamiflu ( oseltamivir ; genentech , san francisco , ca ) for five days and other supportive measures , including fresh frozen plasma , iv - administered vitamin k , lactulose , and prophylactic intravenous antibiotics .
severe infection is characterized by pneumonia , sepsis , septic shock , and multi - organ failure .
extra - pulmonary involvement is rare in uncomplicated human infections.1 studies of mouse models suggest multiple organ localization , including the lungs , heart , thymus , liver , and spleen.4 snchez - torrent et al reported h1n1 encephalitis in a 3-month - old infant from spain.5 hepatic involvement is not frequent and accounts for less than 3% of all cases.1 carrillo - esper et al , in 2010 , reported two adult h1n1 patients with hepatic involvement.1 el - shabrawi et al , in 2011 , reported a 10-month - old child with acute myocarditis and fulminant hepatic failure associated with h1n1.6 the subject of the current case report had acute hepatic failure that presented as jaundice , elevated liver enzymes , and coagulopathy .
most of the other causes of liver failure had been ruled out by relevant investigations .
he responded well to antiviral and other supportive treatment , and showed full clinical and laboratory recovery .
no viral replication is needed to produce hepatic damage , as there is evidence of hepatic oxidative stress and a decrease in antioxidant defenses even when the virus is isolated only from the lungs .
this might be explained by the production of pro - inflammatory cytokines in the respiratory airway that leads to changes in hepatic metabolism and enzymatic activities.7,8
even though hepatic complications are rare in pediatric h1n1 cases , in reporting this case we would like to draw the attention of pediatric health care professionals to the importance of early recognition , focused investigations , diagnosis , and treatment of complicated human h1n1 infection .
 liver involvement in pediatric influenza a ( h1n1 ) infection is rare . focused clinical evaluation and 
 laboratory tests can rule out or identify hepatic complications early on . here 
 we report on a 9-year - old boy treated by the gastroenterology , hepatology , and nutrition unit of al - adan hospital s pediatric department . 
 the patient , who was infected with h1n1 during the 2010 pandemic , showed symptoms of associated acute hepatic failure , was managed conservatively , and recovered completely following treatment . 
 the author would like to draw the attention of pediatricians to the hepatic aspect of human h1n1 infection in order for them to recognize it early and treat it in a timely manner . 
Introduction
Case report
Discussion
Conclusion