P0752 - Autoimmune Hepatitis, Drug-induced Liver Injury or Drug-induced Autoimmune Hepatitis? Diagnostic Dilemma in a Patient With Class III Obesity

Mengdan Xie, MD¹, Shanique Wilson, MD², Lauren Grinspan, MD, PhD³, Kamron Pourmand, MD⁴, Priya Simoes, MBBS^5
1Mount Sinai West and Morningside Hospitals, New York, NY; ²Mount Sinai West, Mount Sinai Morningside and Mount Sinai Beth Israel Hospitals, New York, NY; ³Mount Sinai Hospital, New York, NY; ⁴Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Mount Sinai West and Mount Sinai Morningside Hospitals, New York, NY

Introduction: To differentiate between autoimmune hepatitis(AIH), drug-induced liver injury(DILI) and drug-induced AIH(DI-AIH) required compatible clinical presentation, and characteristic histological and laboratory findings. Here we present a challenging case with limited options for imaging and biopsy due to body habitus.

Case Description/Methods: Case: 38-year-old lady with morbid obesity and hypertension presented with acute onset nausea, fatigue and jaundice for 2 weeks. She denied recent travel, substance abuse, unprotected sex, or family history of liver disease. She started labetalol and some herbal supplements a month prior to presentation.
Her vitals were benign except for BMI 89.2. Physical exam showed jaundice, soft abdomen without tenderness or organomegaly. Laboratory results showed AST 1218, ALT 833, total and direct bilirubin 22.9 and 16.7 respectively, INR 1.7, and IgG 2663. Serologic markers were positive for anti-smooth muscle antibody(ASMA) of 50, and negative for anti-nuclear antibody (ANA) or antimitochondrial antibody(AMA). Other tests including acetaminophen, ceruloplasmin, and acute viral hepatitis panel were negative. Her liver enzymes failed to improve with N-acetylcysteine. Further diagnostic workups including cross-sectional imaging or liver biopsy were unable to perform due to body habitus. She was excluded from EUS-guided biopsy or liver transplantation given high risk intubation.
Working diagnoses were narrowed down to DILI vs. AIH vs. DI-AIH by history and laboratory findings. Benefits outweighing risks, she was started on prednisone 60 mg daily, with transaminases improved to 300s on discharge. She achieved biochemical remission on 6 weeks follow-up. Prednisone was gradually tapered down to 10mg daily over 4 months and switched to budesonide 3 mg daily for maintenance. Immunosuppression withdrawal was planned after 12 months of biochemical remission given possible DILI, DI-AIH in lack of biopsy.

Discussion: The diagnosis of AIH requires compatible biopsy result, characteristic laboratory findings, and exclusion of other liver diseases like DILI and DI-AIH. In rare circumstance when tissue is unavailable, presumptive diagnosis could be made based on typical demographic and laboratory features. Glucocorticoid therapy should be instituted when symptoms or disease activity are severe. Immunosuppression withdrawal could be attempted at 6-12 months when DILI and DI-AIH rank high in differential diagnosis. Laboratory flare after withdrawal suggests AIH.


Disclosures:
Mengdan Xie indicated no relevant financial relationships.
Shanique Wilson indicated no relevant financial relationships.
Lauren Grinspan indicated no relevant financial relationships.
Kamron Pourmand indicated no relevant financial relationships.
Priya Simoes indicated no relevant financial relationships.


Mengdan Xie, MD¹, Shanique Wilson, MD², Lauren Grinspan, MD, PhD³, Kamron Pourmand, MD⁴, Priya Simoes, MBBS⁵. P0752 - Autoimmune Hepatitis, Drug-induced Liver Injury or Drug-induced Autoimmune Hepatitis? Diagnostic Dilemma in a Patient With Class III Obesity, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.