Published online Nov 25, 2017. doi: 10.5495/wjcid.v7.i4.50
Peer-review started: June 15, 2017
First decision: July 20, 2017
Revised: August 2, 2017
Accepted: September 12, 2017
Article in press: September 13, 2017
Published online: November 25, 2017
A 26-year-old male, diagnosed with human immunodeficiency virus (HIV) infection and treated with Efavirenz/Tenofovir disoproxil fumarate/Emtricitabine, was admitted to the emergency room due to jaundice, anti-retroviral treatment was suspended.
Jaundice without right upper quadrant pain or hepatomegaly.
Drug-induced liver injury, viral hepatitis, alcoholic liver disease, neoplasm, acquired immune deficiency syndrome cholangiopathy.
Hyperbilirubinemia with a predominance of direct bilirubin, severe elevation of transaminases and prolongation of the prothrombin time. The serology for hepatotropic viruses was negative (A, B, C and E), viral loads for virus B viral hepatitis, C viral hepatitis, Epstein Bar and cytomegalovirus were undetectable. The antinuclear antibodies were positive with mottled pattern, negative anti-mitochondrial and anti-muscle antibodies and high levels of immunoglobulin G.
The hepato-biliary ultrasound and portal doppler were normal.
Lymphoplasmacytic inflammatory infiltration with eosinophils and severe interface activity, hepatocytes with peri-central inflammation and focal necrosis (“compatible with autoimmune hepatitis”).
Prednisolone of 1 mg/kg per day following tapered doses, Azathioprine 100 mg/qd and cART (Tenofovir disoproxil fumarate/Emtricitabine and Raltegravir).
After literature search, nine reports with only 22 cases of patients with both entities were found, none of them described in Latin America.
Autoimmune hepatitis is a chronic inflammation of the liver of unknown cause, pathogenesis includes environmental triggers, failure of immune tolerance mechanisms, and a genetic predisposition that induce a T cell-mediated immune attack characterized with continuing hepatocellular necroinflammatory and fibrotic process. The diagnosis is based on histologic abnormalities, clinical and laboratory findings, abnormal levels of immunoglobulin G, and one or more characteristic autoantibodies.
Autoimmunity in patients with HIV infection on cART is uncommon, nevertheless in some clinical scenarios should be considered. The differentiation among autoimmune hepatitis (AIH), drug induced liver injury or infectious hepatitis can be challenging and needs an extensive work-up.