An outbreak of acute hepatitis -- an inflammation of the liver -- in children has killed at least four and required liver transplants in more than a dozen others across the globe, according to the World Health Organization. While the cause is undetermined, investigators are studying a family of pathogens, called adenoviruses, that cause a range of illnesses including the common cold.

Symptoms include abdominal pain, diarrhea and vomiting, followed by jaundice, which is marked by the skin or the whites of the eyes turning yellow. Laboratory tests show signs of severe liver inflammation, with markedly high liver enzyme readings. Most of the children didn’t have a fever. Other symptoms of hepatitis include fatigue, loss of appetite, dark urine, light-colored stools and joint pain.

Officials from the Pan American Health Organization (PAHO) said Wednesday that there are more than 220 probable cases of acute hepatitis in children, including nine in the United States.

Enrique Perez, incident manager with PAHO, said during the weekly briefing that since April 5 when the World Health Organization had been notified of these acute hepatitis in previously healthy children under the age of 10, the number of probable cases is now at 228.

While the reported cases, Perez said, were mainly in Europe, other probable cases have also been reported in Western Pacific, South East Asia regions, and the Americas.

British health officials have been investigating the cause of a spike of acute hepatitis, or liver inflammation, among children, and have said there is increasing evidence that it is linked to a common virus.

Adenovirus, a common group of viruses, is now circulating in children at higher than average levels after dropping to unusually low levels during the pandemic. One avenue PAHO and other health officials have ruled out any links to Covid-19 vaccines, saying none of the affected children was vaccinated.

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