Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 21, 2019; 25(35): 5388-5402
Published online Sep 21, 2019. doi: 10.3748/wjg.v25.i35.5388
Autoimmune hepatitis in human immunodeficiency virus-infected patients: A case series and review of the literature
Roongruedee Chaiteerakij, Anapat Sanpawat, Anchalee Avihingsanon, Sombat Treeprasertsuk
Roongruedee Chaiteerakij, Sombat Treeprasertsuk, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
Anapat Sanpawat, Department of Pathology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
Anchalee Avihingsanon, Medical Department, The HIV Netherlands Australia Thailand Research Collaboration, Bangkok 10330, Thailand
Author contributions: Chaiteerakij R was the patients’ hepatologist, reviewed the literature and contributed to manuscript drafting; Sanpawat A performed the pathological diagnosis and contributed to manuscript drafting; Avihingsanon A performed the HIV disease consultation and contributed to manuscript drafting; Treeprasertsuk S were the patients’ hepatologist, reviewed the literature and contributed to manuscript drafting. Chaiteerakij R and Treeprasertsuk S were responsible for the revision of the manuscript for important intellectual content; all authors issued final approval for the version to be submitted.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
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/
Corresponding author: Sombat Treeprasertsuk, MD, PhD, Professor of Internal Medicine, Division of Gastroenterology, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873 Rama IV Road, Patumwan, Bangkok 10330, Thailand. apobtsol@hotmail.com.
Telephone: +66-2-2564265 Fax: +66-2-6524129
Received: June 22, 2019
Peer-review started: June 25, 2019
First decision: July 22, 2019
Revised: August 14, 2019
Accepted: August 24, 2019
Article in press: July 22, 2019
Published online: September 21, 2019
Processing time: 91 Days and 18.3 Hours
Abstract
BACKGROUND

Abnormal liver chemistry is a common problem in human immunodeficiency virus (HIV)-infected patients. Common causes of abnormal liver enzymes in this population include viral hepatitis B/C or opportunistic infection, drug toxicity, and neoplasm. Autoimmune hepatitis is a rare cause of hepatitis in HIV-infected individuals; however, this condition has been increasingly reported over the past few years.

CASE SUMMARY

We present 13 HIV-infected patients (5 males and 8 females) who developed autoimmune hepatitis (AIH) after their immune status was restored, i.e. all patients had stable viral suppression with undetectable HIV viral loads, and median CD4+ counts of 557 cells/× 106 L. Eleven patients presented with chronic persistent elevation of aminotransferase enzyme levels. One patient presented with acute hepatitis and the other patient presented with jaundice. The median levels of aspartate aminotransferase and alanine aminotransferase enzymes were 178 and 177 U/mL, respectively. Elevation of immunoglobulin G levels was present in 11 (85%) patients. Antinuclear antibody and anti-smooth muscle antibody were positive in 11 (85%) and 5 (38%) patients. Liver biopsy was performed in all patients. They had histopathological findings compatible with AIH. The patients were started on prednisolone for remission induction, with good response. After improvement of the liver chemistry, the dose of prednisolone was tapered, and azathioprine was added as life-long maintenance therapy. At the last follow-up visit, all were doing well, without HIV viral rebound or infectious complications.

CONCLUSION

This report underscores the emergence of autoimmune hepatitis in the context of HIV infection.

Keywords: Autoimmune hepatitis; Human immunodeficiency virus; Liver biopsy; Immunosuppression; Autoimmunity; Antiretroviral therapy; Case report

Core tip: Elevated liver enzymes are a common problem in human immunodeficiency virus (HIV)-infected patients. Clinical manifestations of autoimmune hepatitis (AIH) range from no symptoms to mild chronic hepatitis to acute severe hepatitis leading to fulminant hepatic failure or cirrhosis. The diagnosis of AIH requires thorough investigation. It is crucial to perform liver biopsy to confirm the diagnosis. Although rare, AIH should be considered a differential diagnosis in HIV-infected patients presenting with elevated aminotransferase enzyme levels after the exclusion of other common causes of hepatitis. It is believed that this condition occurs due to immune reconstitution inflammatory syndrome (IRIS). Immunosuppressive drugs are the mainstay of treatment and can be used safely in HIV-infected patients.