Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Dec 28, 2017; 9(36): 1367-1371
Published online Dec 28, 2017. doi: 10.4254/wjh.v9.i36.1367
Autoimmune hepatitis in the setting of human immunodeficiency virus infection: A case series
Emmanuel Ofori, Daryl Ramai, Mel A Ona, Madhavi Reddy
Emmanuel Ofori, Daryl Ramai, Madhavi Reddy, Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY 11201, United States
Daryl Ramai, Department of Anatomical Sciences, St. George’s University School of Medicine, Grenada, West Indies
Mel A Ona, Division of Advanced Endoscopy, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
Author contributions: All authors contributed to the acquisition of data, writing and revision of this manuscript.
Informed consent statement: The patient involved in this study gave her written informed consent authorizing use and disclosure of her protected health information.
Conflict-of-interest statement: The authors have no conflicts of interest or financial relationships to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Daryl Ramai, Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, 121 Dekalb Avenue, Brooklyn, NY 11201, United States. dramai@sgu.edu
Telephone: +1-718-2508867
Received: July 28, 2017
Peer-review started: July 30, 2017
First decision: October 9, 2017
Revised: November 16, 2017
Accepted: December 6, 2017
Article in press: December 7, 2017
Published online: December 28, 2017
Processing time: 117 Days and 20.3 Hours
ARTICLE HIGHLIGHTS
Case characteristics

Case 1: A 40-year-old male diagnosed with human immunodeficiency virus (HIV) since 2009 and started on Atripla, with viral suppression and immunological recovery, presented for a follow-up. Case 2: A 44-year-old Hispanic female diagnosed with HIV since 1997 and started on Atripla since 2010, with viral suppression and immunological recovery, was admitted for epigastric pain and vomiting.

Clinical diagnosis

Case 1: Abdominal ultrasound showed a normal sized liver with slight heterogeneity, suggestive of diffuse liver disease. Case 2: An abdominal magnetic resonance (MRI) imaging was suggestive of cirrhosis of the liver.

Differential diagnosis

Liver cirrhosis, hepatitis, hepatocellular carcinoma.

Laboratory diagnosis

Case 1: Laboratory workup showed elevated liver chemistries: Alanine aminotransferase (ALT) 302 U/L, and aspartate aminotransferase (AST) 149 U/L, alkaline phosphatase 233 U/L, total bilirubin 1.3 mg/dL, direct bilirubin 0.6 mg/dL, and alpha-fetoprotein 14 ng/mL. Case 2: Laboratory workup showed elevated liver chemistries: ALT 155 U/L, AST 136 U/L, alkaline phosphatase 100 U/L, total bilirubin 1.9 mg/dL, and alpha-fetoprotein 16 ng/mL.

Imaging diagnosis

Abdominal MRI imaging was suggestive of liver cirrhosis of uncertain etiology.

Pathological diagnosis

Case 1: A transthoracic percussion guided liver biopsy showed fibrous portal expansion, bridging fibrosis, and portal and periportal inflammatory activity with piecemeal necrosis, consistent with autoimmune hepatitis (AIH). Case 2: Liver biopsy showed confluent necrosis infiltrated by dense lymphoplasmacytic infiltrates partially replaced by fibrous tissue, as well as bridging fibrous septa that enclosed regenerative nodules, consistent with AIH.

Treatment

Case 1 was treated with corticosteroids and azathioprine, while case 2 was treated with corticosteroids only.

Related reports

Review of the literature shows that only 18 cases (excluding our two patients) have been reported.

Term explanation

The occurrence of autoimmune hepatitis in the setting of HIV-infected patients is an extremely rare clinical entity. The global prevalence of AIH is largely unknown. Currently, there are no standardized treatment for AIH.

Experiences and lessons

This report suggest that liver biopsies should be performed in HIV patients with an unknown liver disease etiology. HIV patients diagnosed with AIH should be treated with corticosteroids. Further research is needed to study the clinical efficacy of corticosteroids with or without the use of immunosuppression.