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Atypical Presentation of Autoimmune Hepatitis

A 56-year-old female patient came with a 15-day history of jaundice associated with fever and generalised weakness. She was evaluated at a local hospital and all the basic investigations were done. Her liver function tests – Total bilirubin=12.5 (direct >indirect), ALP=177, SGPT (ALT) =415, SGOT (AST) =66, GGTP=105, ALBUMIN=1.6. ANTI-HCV, HBSAG, HAV IGM, HEV IGM, HIV were all negative. Ultrasound abdomen was done which showed mild hepatomegaly, normal CBD, normal spleen and portal vein. No space-occupying lesions. She was labelled as acute viral hepatitis and discharged home.

Due to worsening symptoms, she came to us for further management. Repeat liver function tests showed raising total bilirubin to 22, SGOT from 66 to 700 to 1025, SGPT from 415 to 755 to 1210 and INR from 1.2 to 1.7 to 1.86. The above alarming levels of liver function tests warranted further testing for the cause of liver dysfunction which included ANA, AMA, ASMA, ANTI-LKM1 and SERUM CERULOPLASMIN. The above investigations were all negative except Sr. ANA which was 1+. Clinically, she was deteriorating as she exhibited features of encephalopathy like drowsiness and slowing of responses. She was immediately admitted and commenced on IV fluids, vitamin K, IV antibiotics. Liver biopsy was done which showed marked inflammation with a striking ballooning change of hepatocytes, rosette formation and interface hepatitis-suggestive of autoimmune hepatitis.

IV steroids were started after ruling out sepsis. She improved with it clinically and biochemically and hence discharged and is on regular follow-up. Her LFTS at review have improved steadily. Steroids tapered and started her on azathioprine.

This is a case of a rare presentation of autoimmune hepatitis in the form of acute hepatitis/sub-acute liver failure, which can often be mistaken for acute viral hepatitis. Any patient with altered liver function tests should be evaluated and Followed up closely with LFTs and INR. In case of worsening LFTs/INR/clinical status referral to Gastroenterologist/ A hepatologist is advised to intervene and
prevent acute liver failure.

Dr. K. S. Soma Sekhar Rao, M.D (Gen Med), D.M (Gastro) (Consultant Gastroenterologist, Hepatologist & Therapeutic Endoscopist)

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