Pediatric Hepatitis of Unknown Etiology Medical Record A

PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD ABSTRACTION FORM
CaseID: _________________________________

Form Approved: OMB No. 0920-1011
Exp. Date 01/31/2023

Version 19 Aug 2022

General Instructions:
Please complete the form for all children who meet the case definition: hepatitis of unknown etiology
(with or without adenovirus testing) among children <10 years with aspartate aminotransferase (AST) or
alanine aminotransferase (ALT) (>500 U/L) since October 1, 2021.
Yellow fields do not need to be submitted to CDC.
Greyed out fields do not require information.
CaseID: Please assign using the letter abbreviation for your state/territory followed by a unique ID
(can be either a combination of numeric or alpha characters) assigned by your state
Several sections may be best completed by a clinician: Clinical Info, Diagnosis & Treatment,
Radiologic Findings, Summary of Clinical Assessment.
Vaccination information should be captured from the state Immunization Information System as
the primary source.
Any relevant information that does not fit in a designated section can be noted in the “Summary
of Clinical Assessment” section.
All dates should be in the format MM/DD/YYYY.
Reminder about adenovirus testing:
CDC is recommending adenovirus PCR testing on all specimen types including respiratory, stool,
and blood (including whole blood, plasma or serum) specimens.
CDC requests all residual specimens be submitted to CDC.
Please refer to the specimen protocol for additional instructions on testing/shipping of
specimens. Instructions can be found here: Instructions for Adenovirus Diagnostic Testing,
Typing, and Submission | CDC
Submission Instructions:
CDC requests submission of completed forms on a rolling basis. Please upload completed forms to the
ShareFile folder via one of the following:
1. Scanned/electronic copy of the completed form
2. CSV export from REDCap database (if using CDC REDCap data structure in state/local REDCap
instance)
For questions related to form completion or submission instructions, email [email protected]

1
Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333;
ATTN: PRA (0920-1011)

PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL CHART ABSTRACTION FORM
Version: 19 Aug 2022

CASE ID:_________________________________________________

Date form completed: ____/____/_______
DEMOGRAPHICS
Yellow fields do not need to be submitted to CDC
Patient’s name (Last, First, M.I.) ______________________________________
Age:

□ Days □ Months □ Years

Street Address:

Sex assigned at birth:

□ Male

□ Female

□ Refused

□ Don’t know

Current gender identity: □ Male □ Female
□ Transgender □ None of these

City:

County:

Phone (Cell/Home): _________________________
Ethnicity:

DOB: ____/____/_______

□ Hispanic or Latino
□ Not Hispanic or Latino
□ Unknown

State:

Zip:

_____________

Phone (Cell/Home): _________________________

Race
□ American Indian/Alaska Native □ Native Hawaiian/Pacific Islander
(check all that apply) □ Asian
□ White
□ Black/African American
□ Other (________________)

SIGNS/SYMPTOM HISTORY
Category of signs/symptoms
First Respiratory sign/symptom Onset:

Check all that apply:
□ Cough
□ Congestion □ Rhinorrhea
□ Sore throat
□ Wheezing
□ Shortness of breath
□ Conjunctivitis (pink eye)
□ Diarrhea
□ Nausea
□ Vomiting
□ Abdominal Pain
□ Dark-colored urine
□ Pale stool
□ Jaundice or scleral icterus
□ Fatigue
□ Fever (Max) ________ °F
□ Decreased appetite
□ Other, specify:

____/_____/____
□ Unknown

First GI sign/symptom Onset:

_____/_____/______
□ Unknown
First Hepatitis sign/symptom Onset: _____/_____/______
□ Unknown
Date of systemic sign/symptom Onset: _____/_____/______
□ Unknown

CLINICAL INFORMATION
Yellow fields do not need to be submitted to CDC.
For date of initial evaluations, please note the date that the child first sought medical care for this illness.
Patient Height: __________ □ ft/in □ cm □ Unknown

Patient Weight: ___________ □ Ibs □ Kg □ Unknown

Date of initial evaluation (for this illness): _____/_____/______ □ Unknown
□ Primary care provider
Where was the patient first
□ Urgent care
identified?
□ Emergency department
□ Hepatologist/subspecialty appointment
Was the patient hospitalized for this illness?
If patient was hospitalized:

□ Hospital
□ Unknown
□ Other, specify
_____________________

Name of facility:
________________________

□ Yes □ No □ Unknown

Hospital: __________________________

Medical Record #:

_________

Admission Date (Initial Hospital):____/____/_______ □ Unknown admission date
Was the patient transferred from another hospital?

□ Yes □ No □ Unknown

If yes, which hospital? _________________________ Transfer Date: ___/___/______ □ Unknown
Final patient outcome: □ Survived, discharge home
□ Survived, discharged other location
□ Died If yes, was an autopsy performed? □ Yes
□ Unknown

□ No

□ Unknown

Date of discharge / death: _____/_____/_______ □ Unknown date of discharge/death
If patient was hospitalized:

ICD-10 discharge codes:
Primary code:

Other codes (list up to 10):

Were there additional codes beyond those listed above:

□ Yes

□ No

□ Unknown

PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL CHART ABSTRACTION FORM
Version: 19 Aug 2022

CASE ID:_________________________________________________

DIAGNOSES & TREATMENT
Yellow fields do not need to be submitted to CDC.
Was the patient diagnosed with any of the following measures of severity of hepatitis/liver disease:
Hepatomegaly (enlarged liver)
□ Yes □ No □ Unknown
Splenomegaly (enlarged spleen)
□ Yes □ No □ Unknown
Ascites
□ Yes □ No □ Unknown
Acute liver failure (rapid loss of liver function)
□ Yes □ No □ Unknown
Hepatic encephalopathy (loss of brain function due to liver failure)
□ Yes □ No □ Unknown
Hemophagocytic lymphohistiocytosis (buildup of white blood cells in organs)
□ Yes □ No □ Unknown
Was the patient diagnosed with pneumonia at time of clinical presentation/hospitalization?
□ Yes □ No □ Unknown
If yes, which hospital?
Did patient receive a liver
Date of 1st Transplant: ______/______/________
□ Yes □ No □ Unkn _______________________
transplant?
□ Date Unknown
__
nd
Did patient receive a second
If yes, which hospital?
Date of 2 Transplant: ______/______/________
□ Yes □ No □ Unkn
transplant?
_____________________
□ Date Unknown
Was the patient treated with:

…cidofovir?

□ Yes

□ No

□ Unknown

…brincidofovir?

□ Yes

□ No

□ Unknown

…steroids?

□ Yes

□ No

… Intravenous Immunoglobulin (IVIg)?

□ Unknown If treated with steroids, please specify: _________________
□ Yes

□ No

□ Unknown

UNDERLYING HEALTH CONDITIONS
Did the patient have any of the following underlying health conditions? □ Yes
□ No
□ Unknown
If yes, check all that apply:
□ Asthma (or Reactive Airway Disease)
□ Other cancer, specify___________________________________
□ Congenital Heart Disease
□ Developmental disorder, specify__________________________
□ Diabetes Mellitus (Type 1 or 2)
□ Premature Birth (Gestational age at birth: ___________ weeks)
□ Leukemia/Lymphoma
□ History of any transplant, specify _________________________
□ Sickle cell anemia
□ Other condition, specify ________________________________
□ Seizure/Seizure disorder

ADENOVIRUS TESTING
Provide information on any repeat testing or multiple sample types in the ‘Other sample, specify’ fields and write-in the specimen type.
Specimen Collection
Is specimen available
Diagnostic Test
Tested/Result
Date (mm/dd/yyyy)
for shipping to CDC?
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
Stool
□ Yes □ No □ Unkn
If tested, specify type: □ Multipanel PCR
□ Other PCR □ Antigen
Respiratory or throat
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
□ Yes □ No □ Unkn
If tested, specify type: □ Multipanel PCR
□ Other PCR □ Antigen
Whole blood
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
□ Yes □ No □ Unkn
Plasma

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

□ Yes □ No □ Unkn

Serum
Other sample, specify
___________________
Other sample, specify
___________________
Other sample, specify
___________________

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

□ Yes □ No □ Unkn

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

□ Yes □ No □ Unkn

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

□ Yes □ No □ Unkn

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

□ Yes □ No □ Unkn

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Diagnostic test

Blood qPCR

Adenovirus typing
results

CASE ID:_________________________________________________

Specimen Collection
Date (mm/dd/yyyy)

Value and units

Specimen type

_________

□ copies/mL

□ IU/mL

□ Whole blood

□ Plasma

□ Serum

_________

□ copies/mL

□ IU/mL

□ Whole blood

□ Plasma

□ Serum

_________

□ copies/mL

□ IU/mL

□ Whole blood

□ Plasma

□ Serum

_________

□ copies/mL

□ IU/mL

□ Whole blood

□ Plasma

□ Serum

_________

□ copies/mL

□ IU/mL

□ Whole blood

□ Plasma

□ Serum

☐ Not Sent (not typed)

☐ Type 41

☐ Could not be typed

☐ Other type, specify_________

☐ Pending

HEPATITIS VIRUS TESTING
If specimen collection date is not available, use date of laboratory result
Diagnostic Test
Tested/Result

Date Specimen Collected (mm/dd/yyyy)

Hepatitis A
IgM anti-HAV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

IgG anti-HAV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

Total anti-HAV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HAV RNA

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HBsAg

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

IgM anti-HBc

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

Total anti-HBc

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HBeAg

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HBV DNA

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

anti-HCV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HCV RNA

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

anti-HDV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HDV RNA

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

IgM anti-HEV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

IgG anti-HEV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HEV RNA

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

Hepatitis B

Hepatitis C

Hepatitis D

Hepatitis E

GASTROINTESTINAL TESTING
Greyed out fields do not require information. If multiple stool samples were collected/tested, mark pathogens detected on any specimen and provide
details in the “Summary of Clinical Assessment” section.
Date of first specimen collection
□ Yes □ No, skip to next section □ Unknown
Was a stool specimen collected for testing?
_____/_____/______
Gastrointestinal panel testing
Test Performed

□ Yes
□ No
□ Unknown

Test Type
□ Luminex xTAG
□ Biofire / FilmArray
□ Other:
________________
□ Unknown

Pathogens Detected (check all that apply)
□ Vibrio
□ No pathogens detected
□ Vibrio cholerae
□ Enteroaggregative E. coli (EAEC)
□ Campylobacter
□ Enteropathogenic E. coli (EPEC)
□ Clostridium difficile
□ Enterotoxigenic E. coli (ETEC) lt/st
□ Plesiomonas shigelloides
□ Shiga-like toxin-producing E. coli (STEC)
□ Salmonella
□ E. coli O157
□ Yersinia enterocolitica
□ Shigella/Enteroinvasive E. coli (EIEC)

□ Cryptosporidium
□ Cyclospora cayetanensis
□ Entamoeba histolytica
□ Giardia lamblia
□ Astrovirus
□ Norovirus GI/GII
□ Rotavirus A
□ Sapovirus (I, II, IV and V)

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CASE ID:_________________________________________________

Non-panel tests
Pathogen

Tested/Result

Test Type

Details
If positive, pathogen:

Bacterial culture

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

Norovirus

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Sapovirus

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Astrovirus

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Rotavirus

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ EIA
□ Other: _________

Ova & Parasite

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ GI □GII □ Not specified
□ I □ II □ III □ IV
□ Not specified
□ Type:
□ Not specified
□ Genotype:
□ Not specified
If positive, pathogen
isolated: _____________

C. difficile

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

Name of test:
_____________

RESPIRATORY TESTING
Greyed out fields do not require information
□ Yes □ No □ Unknown
Was a respiratory specimen collected
If yes, specify specimen type
Date of specimen collection _____/_____/______
for testing?
___________________
Respiratory panel testing
Test
Test Type
Pathogens Detected (check all that apply)
Performed
□ No pathogens
□ Human Metapneumovirus
□ Parainfluenza Virus 1
□ Luminex NxTAG RPP
detected
□ Human Rhinovirus/Enterovirus
□ Parainfluenza Virus 2
□ Luminex NxTAG RPP + SARS-CoV-2
□ Influenza A
□ Parainfluenza Virus 3
□ Yes
□ Luminex VERIGENE RP Flex
□ Coronavirus HKU1
□ Influenza A/H1
□ Parainfluenza Virus 4
□ No
□ Biofire / FilmArray RPP
□ Coronavirus NL63
□ Influenza A/H3
□ Bordetella parapertussis
□ Unknown
□ Biofire / FilmArray PN
□ Coronavirus 229E
□ Influenza A/H1-2009
□ Bordetella pertussis
□ Other: ___________________
□ Coronavirus OC43
□ Influenza B
□ Chlamydia pneumoniae
□ Unknown
□ SARS-CoV-2
□ Respiratory Syncytial Virus
□ Mycoplasma pneumoniae
□ Other :
Other respiratory specimen tests conducted
Pathogen

Tested/Result

SARS-CoV-2 PCR

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

SARS-CoV-2 Antigen
SARS-CoV-2, Serology
(anti-nucleocapsid)
SARS-CoV-2, Serology
(anti-spike)
SARS-CoV-2, Other
specify______________
Other test (specify):
____________________
Other test (specify):
____________________

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

Details

Date (mm/dd/yyyy)

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

If positive, pathogen
isolated:
If positive, pathogen
isolated:

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CASE ID:_________________________________________________

OTHER VIRAL TESTING
Pathogen/ Test Type

Tested/Result

Test/Specimen Type
□ Whole blood PCR
□ Plasma PCR
□ Whole blood PCR
□ Plasma PCR

Cytomegalovirus- PCR

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

Epstein-Barr virus (EBV)- PCR

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

EBV- Viral Capsid Antigen IgG

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

EBV- Viral Capsid Antigen IgM

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

EBV- Nuclear Antigen (EBNA) IgG

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

EBV- Early antigen (EA) IgG
Human herpesvirus 6

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Human herpesvirus 7

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Varicella-zoster virus

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Enterovirus

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Human immunodeficiency virus

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Parvovirus B19

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Herpes simplex virus-1

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Herpes simplex virus-2

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Measles

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Leptospirosis

□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn

□ PCR □ Other:

Date (mm/dd/yyyy)

PATIENT HISTORY OF COVID-19
List the most recent positive test. Any additional positive tests can be noted in the “Summary of clinical assessment” section.
Has this patient previously tested positive for SARS-CoV-2? (before current illness)
Positive test
□ Yes □ No

Test Type
□ Unknown

□ PCR

Date (most recent, mm/dd/yyyy)

□ Antigen

□ Serology

□ Unknown

□ Date Unknown

LABORATORY MARKERS
Greyed out fields do not require information
Test Name

Initial Value

Date (mm/dd/yyyy)

Highest Value

Date (mm/dd/yyyy)

Alanine aminotransferase (ALT, U/L)
Aspartate aminotransferase (AST, U/L)
Total bilirubin (mg/dL)
Conjugated bilirubin (mg/dL)
Unconjugated bilirubin (mg/dL)
INR (International Normalized Ratio)
Alkaline phosphatase (ALP, U/L)
Ammonia (µg/dL)
Prothrombin time (PT)
White blood cell (WBC) count (Cells x 109/L)
Total Lymphocyte Count (Cells x 103/µL)
Absolute Neutrophil Count (Cells x 103/µL)
Hemoglobin (HGB, g/dL)
Platelets (Plt, Cells x 109/L)
Sodium (Na, mEq/L)
Chloride (Cl, mmol/L)

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CASE ID:_________________________________________________

Potassium (K, mEq/L)
Carbon dioxide (C02, mmol/L)
Blood urea nitrogen (BUN, mg/dL)
Creatinine (mg/dL)
Glucose (mg/dL)
Calcium (mg/dL)
Albumin (g/dL)
Uric acid (UA, mg/dL)
Fibrinogen
C-reactive protein (CRP, mg/dL)
Erythrocyte Sedimentation Rate (ESR, mm/hr)
Antinuclear antibody (ANA)
Smooth muscle antibody (ASMA)
Liver kidney microsomal antibody (LKM)
Immunoglobulin (IgG)

TOXICOLOGY
Provide highest value (and date) and put information on any additional tests in the “Summary of Clinical Assessment” section.
Was a test for acetaminophen drug levels
□ Yes □ No □
If yes, drug level (mcg/mL):_______ Date: _____/_____/______
conducted?
Unkn

RADIOLOGIC FINDINGS
This section is best completed by a clinician. If there are multiple ultrasounds/CTs, list the date of first test and enter dates/ findings of additional
tests in the key findings field for that test (i.e. CT, ultrasound, etc.)
Were any of the following conducted:
Imaging Study

Conducted

Abdominal ultrasound

□ Yes □ No □ Unkn

Abdominal CT scan

□ Yes □ No □ Unkn

Abdominal MRI

□ Yes □ No □ Unkn

Other, specify_____________

□ Yes □ No □ Unkn

Other, specify_____________

□ Yes □ No □ Unkn

Other, specify_____________

□ Yes □ No □ Unkn

Other, specify_____________

□ Yes □ No □ Unkn

Date (mm/dd/yyyy)

Key Findings

PATHOLOGIC FINDINGS
Please complete the liver biopsy section or native liver explant section (or both) based on the type of liver tissue specimen collected.
Did the patient have liver tissue analyzed by pathology?

□ Yes

□ No

□ Unknown

(If no, skip to next section)

Liver biopsy (complete below for Liver biopsy specimens)
Liver biopsy
specimen collected

□ Yes

□ No (If no, skip to native liver explant section)

□ Unkn

Specimen collection date:

If yes… What were the findings of the liver biopsy (check all that apply)
□ Acute/active hepatitis
□ Autoimmune hepatitis
□ Bile duct injury/inflammation
□ Chronic hepatitis

□ Fibrosis
□ Hemophagocytosis
□ Interface hepatitis
□ Microvesicular steatosis

□ Macrovesicular steatosis
□ Portal inflammation/hepatitis
□ Smudge cells
□ Viral/intranuclear inclusions

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…Was there hepatocellular necrosis?
select type (check all that apply):
□ Single Cell
□ Confluent
□ Piecemeal
□ Diffuse/Massive

CASE ID:_________________________________________________

□ Yes □ No
Other findings, specify:

□ Unknown

…What were the results for Adenovirus immunohistochemistry/immunostaining? □ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
…Was other immunohistochemistry performed?

□ Yes

□ No

□ Unknown

If other immunohistochemistry performed, what were the results:
Pathogen

Tested/Result

HSV1

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HSV2

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

CMV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

VZV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

Measles
Other pathogen(s), specify:

□ Not tested
□ Not tested

□ Pos
□ Pos

□ Neg
□ Neg

□ Indeterm
□ Indeterm

□ Pending
□ Pending

□ Unkn
□ Unkn

… Was adenovirus PCR testing conducted?

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

… Was adenovirus in situ hybridization conducted?

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

Native liver explant (post liver transplant) (Complete below for liver explant specimens)
Liver explant specimen collected

□ Yes

□ No

□ Unknown

Specimen collection date:

If yes… What were the findings from the liver explant (check all that apply)
□ Acute/active hepatitis
□ Autoimmune hepatitis
□ Bile duct injury/inflammation
□ Chronic hepatitis

□ Fibrosis
□ Hemophagocytosis
□ Interface hepatitis
□ Microvesicular steatosis

□ Macrovesicular steatosis
□ Portal inflammation/hepatitis
□ Smudge cells
□ Viral/intranuclear inclusions

…Was there hepatocellular necrosis?
□ Yes □ No □ Unknown
select type (check all that apply):
□ Single Cell
□ Confluent
Other findings, specify:
□ Piecemeal
□ Diffuse/Massive
…What were the results for Adenovirus immunohistochemistry/immunostaining? □ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unkn
…Was other immunohistochemistry performed?

□ Yes

□ No

□ Unknown

If other immunohistochemistry performed, what were the results:
Pathogen

Tested/Result

HSV1

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

HSV2

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

CMV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

VZV

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unkn

Measles
Other pathogen(s), specify:

□ Not tested
□ Not tested

□ Pos
□ Pos

□ Neg
□ Neg

□ Indeterm
□ Indeterm

□ Pending
□ Pending

□ Unkn
□ Unkn

□ Not tested
□ Not tested

□ Pos
□ Pos

□ Neg
□ Neg

□ Indeterm
□ Indeterm

□ Pending
□ Pending

□ Unkn
□ Unkn

… Was adenovirus PCR testing conducted?
… Was adenovirus in situ hybridization conducted?

8

PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL CHART ABSTRACTION FORM
Version: 19 Aug 2022

CASE ID:_________________________________________________

SUMMARY OF CLINICAL ASSESSMENT
Use this section to add any additional relevant information and indicate the likely cause of the patient’s hepatitis based on the clinician’s
judgement/assessment
Based on the diagnostic workup, is there a most likely cause of this patient’s hepatitis?
□ Hepatitis D
□ Hepatitis E
□ Autoimmune hepatitis
□ Wilson’s disease

□ Adenovirus
□ Herpes simplex virus
□ EBV
□ CMV
□ VZV
Any other clinically relevant information?

□ Medication toxicity, if yes specify____________________________
□ Other viral infection, specify________________________________
□ Other, specify ___________________________________________
□ Remains unknown

VACCINATION INFORMATION
Information on vaccinations received should be captured from the state Immunization Information System as the primary source.
For SARS-CoV-2 vaccination, please indicate the vaccine manufacturer for each dose.
Greyed out fields do not require information.
Vaccination
Date Dose 1
Date Dose 2
Date Dose 3
Date Dose 4
Date Dose 5
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Hepatitis B
Rotavirus
DTaP/Tdap
Hib
PCV13
IPV
MMR
Varicella
Hepatitis A
SARS-CoV-2
(add vaccine
manufacturer below
date)
Influenza*

Manufacturer:

Manufacturer:

Manufacturer:

Additional vaccines
/ doses
(list vaccine & date)
*past year only

9