Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Infect Dis. Nov 25, 2017; 7(4): 50-57
Published online Nov 25, 2017. doi: 10.5495/wjcid.v7.i4.50
Autoimmune hepatitis in human immunodeficiency virus infection: Case report and literature review
Ivan Noreña, Jairo A Morantes-Caballero, Andrés Garcés, Brian José Gómez, Gabriel Rodríguez, Carlos Saavedra, William Otero
Ivan Noreña, Gabriel Rodríguez, Carlos Saavedra, Infectious Diseases Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
Jairo A Morantes-Caballero, Andrés Garcés, Brian José Gómez, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
William Otero, Gastroenterology Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
Author contributions: All authors contributed to the acquisition of data, writing, and revision of this manuscript.
Institutional review board statement: This case report was exempt from the Institutional Review Board standards at Universidad Nacional de Colombia.
Informed consent statement: The patient gave his written informed consent authorizing use and disclosure of his protected health information.
Conflict-of-interest statement: All the authors have no conflicts of interests to declare.
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: Jairo A Morantes-Caballero, Professor of Internal Medicine I, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Carrera 30 No. 45-03. Facultad de Medicina, Edificio 471, Oficina 510, Bogotá 111321, Colombia. jamorantesc@unal.edu.co
Telephone: +57-1-3165000 Fax: +57-1-3165000
Received: June 12, 2017
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
Processing time: 161 Days and 1.7 Hours
ARTICLE HIGHLIGHTS
Case characteristics

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.

Clinical diagnosis

Jaundice without right upper quadrant pain or hepatomegaly.

Differential diagnosis

Drug-induced liver injury, viral hepatitis, alcoholic liver disease, neoplasm, acquired immune deficiency syndrome cholangiopathy.

Laboratory diagnosis

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.

Imaging diagnosis

The hepato-biliary ultrasound and portal doppler were normal.

Pathological diagnosis

Lymphoplasmacytic inflammatory infiltration with eosinophils and severe interface activity, hepatocytes with peri-central inflammation and focal necrosis (“compatible with autoimmune hepatitis”).

Treatment

Prednisolone of 1 mg/kg per day following tapered doses, Azathioprine 100 mg/qd and cART (Tenofovir disoproxil fumarate/Emtricitabine and Raltegravir).

Related reports

After literature search, nine reports with only 22 cases of patients with both entities were found, none of them described in Latin America.

Term explanation

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.

Experiences and lessons

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.