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Mihai IR, Rezus C, Burlui MA, Cardoneanu A, Macovei LA, Richter P, Bratoiu I, Rezus E. Autoimmune Liver Diseases and Rheumatoid Arthritis-Is There an Etiopathogenic Link? Int J Mol Sci 2024; 25:3848. [PMID: 38612658 PMCID: PMC11011907 DOI: 10.3390/ijms25073848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 02/28/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
Rheumatoid arthritis (RA) is a systemic immune-mediated disease that, in addition to the articular involvement, can have extra-articular manifestations. Even though liver damage in RA is not very common, associated autoimmune liver diseases (AILDs) may occur. The most common AILD associated with RA is primary biliary cirrhosis (PBC), followed by autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC). There are common underlying mechanisms that play a role in the emergence of autoimmunity and inflammation in both rheumatic and autoimmune liver diseases. Genetic studies have revealed the existence of several common disease-associated genes shared between RA and AILDs, and infectious triggers, particularly those associated with recurrent or complicated urinary tract infections, are also speculated to be potential triggers for these conditions. Moreover, these diseases share common serologic patterns characterized by the presence of specific autoantibodies and hyper-gammaglobulinemia. In this study, we focus on reviewing the association between RA and AILDs regarding the prevalence and possible etiopathogenic link.
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Affiliation(s)
- Ioana Ruxandra Mihai
- Department of Rheumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania (L.A.M.); (E.R.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- “Sfantul Spiridon” Emergency Hospital, 700111 Iasi, Romania
| | - Maria Alexandra Burlui
- Department of Rheumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania (L.A.M.); (E.R.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Anca Cardoneanu
- Department of Rheumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania (L.A.M.); (E.R.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Luana Andreea Macovei
- Department of Rheumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania (L.A.M.); (E.R.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania (L.A.M.); (E.R.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania (L.A.M.); (E.R.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania (L.A.M.); (E.R.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
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Fernandes B, Dias E, Mascarenhas-Saraiva M, Bernardes M, Costa L, Cardoso H, Macedo G. Rheumatologic manifestations of hepatic diseases. Ann Gastroenterol 2019; 32:352-360. [PMID: 31263357 PMCID: PMC6595923 DOI: 10.20524/aog.2019.0386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
The course of hepatic diseases may be complicated by a multitude of rheumatologic manifestations, which can complicate the diagnostic approach and alter the natural history of primary liver disease, sometimes worsening prognosis due to associated multiple organ dysfunction. These manifestations can occur in association with a multitude of liver diseases, including viral hepatitis, autoimmune hepatitis, alcoholic liver disease, nonalcoholic fatty liver disease, hemochromatosis, or Wilson’s disease. It is necessary not only for rheumatologists, but also for other clinicians, to be aware that these atypical manifestations may reflect an undiagnosed hepatic disease. On the other hand, it is crucial that, in a patient with known hepatic disease presenting with rheumatologic symptoms, an accurate distinction be made between the rheumatologic manifestations of hepatic disease and primary rheumatologic disease, since the treatment is often different. This review aims to summarize the current evidence regarding rheumatologic manifestations of hepatic diseases, how to distinguish them from primary rheumatologic disorders, and how to provide adequate management.
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Affiliation(s)
- Bruno Fernandes
- Rheumatology Department (Bruno Fernandes, Miguel Bernardes, Lúcia Costa)
| | - Emanuel Dias
- Gastrenterology Department (Emanuel Dias, Miguel Mascarenhas-Saraiva, Hélder Cardoso, Guilherme Macedo), Centro Hospitalar de São João, Porto, Portugal
| | - Miguel Mascarenhas-Saraiva
- Gastrenterology Department (Emanuel Dias, Miguel Mascarenhas-Saraiva, Hélder Cardoso, Guilherme Macedo), Centro Hospitalar de São João, Porto, Portugal
| | - Miguel Bernardes
- Rheumatology Department (Bruno Fernandes, Miguel Bernardes, Lúcia Costa)
| | - Lúcia Costa
- Rheumatology Department (Bruno Fernandes, Miguel Bernardes, Lúcia Costa)
| | - Hélder Cardoso
- Gastrenterology Department (Emanuel Dias, Miguel Mascarenhas-Saraiva, Hélder Cardoso, Guilherme Macedo), Centro Hospitalar de São João, Porto, Portugal
| | - Guilherme Macedo
- Gastrenterology Department (Emanuel Dias, Miguel Mascarenhas-Saraiva, Hélder Cardoso, Guilherme Macedo), Centro Hospitalar de São João, Porto, Portugal
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Floreani A, De Martin S, Secchi MF, Cazzagon N. Extrahepatic autoimmunity in autoimmune liver disease. Eur J Intern Med 2019; 59:1-7. [PMID: 30360943 DOI: 10.1016/j.ejim.2018.10.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 02/07/2023]
Abstract
The most important autoimmune liver disease include: autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis. In general, about one in three patients with an autoimmune liver disease have a concomitant extrahepatic autoimmune disease, which may include rheumatological, endocrinological, gastrointestinal, pulmonary or dermatological conditions. The pathogenesis of these conditions includes the production of both innate and adaptive immune responses targeting cholangiocytes as well as different extrahepatic tissues. In this sense, extrahepatic autoimmunity represent a continuous spectrum of autoimmunity involving liver and extrahepatic tissues. This review aims to focus the clinical and pathophysiological aspects of extrahepatic autoimmunity associated to autoimmune liver diseases.
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Affiliation(s)
- Annarosa Floreani
- Dept of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, 35128, Italy.
| | - Sara De Martin
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
| | - Maria Francesca Secchi
- Dept of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, 35128, Italy
| | - Nora Cazzagon
- Dept of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, 35128, Italy
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Selmi C, Generali E, Gershwin ME. Rheumatic Manifestations in Autoimmune Liver Disease. Rheum Dis Clin North Am 2018; 44:65-87. [DOI: 10.1016/j.rdc.2017.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Lin P, Jiang CM. Latest advances in diagnosis of autoimmune liver disease. Shijie Huaren Xiaohua Zazhi 2016; 24:4085-4091. [DOI: 10.11569/wcjd.v24.i29.4085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Autoimmune liver disease (AILD) includes autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, and overlap syndromes. AILD is the main inducing factor for late chronic liver failure, and in Western countries it is also one of the major liver diseases for which orthotopic liver transplantation is performed. In recent years, with the increasing incidence of AILD in both China and other countries, clinicians have paid more and more attention to AILD. Further standardization of diagnostic criteria for AILD has become a new hot research topic, and experts and scholars have put forward some corresponding opinions. This article describes the latest advances in the diagnosis of AILD.
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Utiyama SRR, Zenatti KB, Nóbrega HAJ, Soares JZC, Skare TL, Matsubara C, Muzzilo DA, Nisihara RM. Rheumatic Disease Autoantibodies in Autoimmune Liver Diseases. Immunol Invest 2016; 45:566-73. [PMID: 27409579 DOI: 10.1080/08820139.2016.1186173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Autoimmune liver diseases (ALDs) are known to be associated with systemic autoimmune rheumatic diseases (SARDs) and their autoantibodies. We aimed to study the prevalence of SARDs and related autoantibodies, as well as their prognostic implications in a group of patients with ALDs. METHODS This was a cross-sectional study. Sixty patients with ALDs (38.3% with autoimmune hepatitis; 11.7% with primary biliary cirrhosis; 25% with primary sclerosing cholangitis and 25% with overlap syndrome) were studied for the presence of SARDs and their autoantibodies. RESULTS There was autoimmune rheumatic disease in 20% of the studied sample. Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) were the commonest (11.6% and 5%, respectively). Antinuclear antibodies (ANAs) were present in 35% of the patients, followed by anti-Ro (20.0%); anti-nucleosome (18.3%); rheumatoid factor (10%) anti-CCP (8.3%); anti-RNP (8.3%); anti-ds-DNA (6.6%); anti-La (3.3%); anti-Sm (3.3%), anti-ribosomal P (3.3%). Anti-Ro (p = 0.0004), anti-La (p = 0.03), anti-RNP (p = 0.04) and anti-Sm (p = 0.03) were commonly found in patients with SARD, but not anti-DNA, anti-nucleosome and anti-ribosomal P. No differences were found in liver function tests regarding to the presence of autoantibodies. CONCLUSIONS There was a high prevalence of SARD and their autoantibodies in ALD patients. Anti-Ro, anti-La, anti-RNP and anti-Sm positivity points to an association with systemic autoimmune rheumatic diseases. The presence of autoantibodies was not related to liver function tests.
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Affiliation(s)
- Shirley R R Utiyama
- a Immunopathology Laboratory , Clinics Hospital of Federal University of Paraná , Curitiba , Paraná , Brazil.,b Department of Clinical Analysis , Federal University of Paraná , Curitiba , Paraná , Brazil
| | - Katiane B Zenatti
- c Rheumatology Unit of Evangelic University Hospital , Curitiba , Paraná , Brazil
| | - Heloisa A J Nóbrega
- c Rheumatology Unit of Evangelic University Hospital , Curitiba , Paraná , Brazil
| | - Juliana Z C Soares
- a Immunopathology Laboratory , Clinics Hospital of Federal University of Paraná , Curitiba , Paraná , Brazil
| | - Thelma L Skare
- c Rheumatology Unit of Evangelic University Hospital , Curitiba , Paraná , Brazil
| | - Caroline Matsubara
- a Immunopathology Laboratory , Clinics Hospital of Federal University of Paraná , Curitiba , Paraná , Brazil
| | - Dominique A Muzzilo
- d Hepatology Unit , Clinics Hospital of Federal University of Paraná , Curitiba , Paraná , Brazil
| | - Renato M Nisihara
- a Immunopathology Laboratory , Clinics Hospital of Federal University of Paraná , Curitiba , Paraná , Brazil.,e Department of Medicine , Positivo University , Curitiba , Paraná , Brazil
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Abstract
Autoimmune hepatitis (AIH) is a chronic liver disease of unknown etiology. It is composed of immune-mediated liver injury and significant immunological aspects. Arthritis can be observed in patients with AIH before recognition of the disease, which can lead to a diagnostic challenge. Although there are few reported cases in literature, peripheral blood eosinophilia might also play a part in such diagnosis. We report an intriguing case of a 41-year-old man who presented to our service with arthritis and eosinophilia as initial manifestations and was eventually diagnosed with overlap syndrome: AIH and primary sclerosing cholangitis. The present report aims to include eosinophilia among the clinical features of AIH, highlighting the possibility of its detection before the onset of either articular or hepatic disturbances.
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Ikeda T, Kaminaka C, Yamamoto Y, Furukawa F. Disseminated cryptococcosis-induced skin ulcers in a patient with autoimmune hepatitis. Case Rep Dermatol 2014; 6:98-102. [PMID: 24761142 PMCID: PMC3995400 DOI: 10.1159/000360978] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report the case of a 68-year-old woman with autoimmune hepatitis (AIH) who had leg ulcers induced by disseminated cryptococcosis. She had received prednisolone for her AIH at 20 mg/day for maintenance. On the initial visit, she complained of a painful ulcer that had round, shallow pockets with erythema and erythematous subcutaneous indurations on the right thigh. Several metacarpophalangeal joints and wrist joints were swollen, with tenderness and stiffness in the morning for over 3 h. Her serum rheumatoid factor was high. Since other autoimmune disorders such as rheumatoid arthritis can present with AIH, it was necessary to distinguish it from ulcers due to rheumatoid arthritis, although the characteristic features of these ulcers seemed to be different. A biopsy specimen from the erythematous skin showed globe-shaped organisms in the dermis and subcutaneous tissues; vasculitis and phlebostasis were not observed. The results from computed tomography scans and sputum culture led to the diagnosis of disseminated cryptococcosis. The administration of fluconazole, fosfluconazole, and voriconazole for about 2 months improved the cryptococcal pneumonia, but the size of the skin ulcer enlarged. The administration was changed to itraconazole, which reduced the size. Cryptococcal infections occur more commonly in immunocompromised hosts, including patients under immunosuppressive therapies such as corticosteroids. The possibility that the skin ulcers in immunocompromised hosts may be caused by cryptococcosis should be considered.
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Affiliation(s)
- Takaharu Ikeda
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Chikako Kaminaka
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Yuki Yamamoto
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Fukumi Furukawa
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
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Komorbidität rheumatischer und hepatologischer Erkrankungen. Z Rheumatol 2013; 72:547-54. [DOI: 10.1007/s00393-012-1116-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Autoimmune hepatitis (AIH) is a generally progressive, chronic liver disease of unknown etiology, relatively uncommon, associated with chronic hepatic inflammation. An environmental agent is hypothesized to trigger an immune-mediated attack directed against liver antigens in genetically predisposed individuals. The disease can lead to potentially fatal liver dysfunction. AIH is characterized by female predominance (sex ratio 3.6:1), hypergammaglobulinemia, circulating autoantibodies and association with human leukocyte antigens DR3 or DR4. The diagnosis of AIH is based on the revised descriptive criteria reported by the International Autoimmune Hepatitis Group in 1999. Without appropriate immunosuppressive therapy AIH has a very poor prognosis with 10-year survival rates as low as 10%, but usually very good response to immunosuppression, and survival rates of responders to the treatment are similar to those of healthy counterparts from the same population.
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Affiliation(s)
- Jan Lata
- Faculty of Medicine, University of Ostrava, Czech Republic.
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Abstract
BACKGROUND Although the pathomechanisms of autoimmune diseases in various organs remain unresolved, an accumulation of autoimmune diseases in individual patients has been observed. An overlap of autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) or primary sclerosing cirrhosis has been well documented. However, the overlap of autoimmune diseases other than PBC or PSC has not yet been investigated in a large cohort. GOAL The goal of our analysis was to investigate the incidence of concurrent autoimmune diseases in patients with AIH. STUDY We analyzed our cohort of 278 patients with AIH for concurrent autoimmune diseases. RESULTS A total of 111 patients (40%) were diagnosed with additional autoimmune diseases. Besides overlap syndromes for PBC and PSC, autoimmune thyroiditis was the most common concurrent disease (28 patients, 10%). Other concurrent autoimmune diseases comprised vitiligo (5 patients), rheumatoid arthritis (5 patients), Sjogren syndrome (4 patients), ulcerative colitis (4 patients), conjunctivitis (4 patients), celiac disease (3 patients), systemic lupus erythematodes (2 patients), type I diabetes (2 patients), multiple sclerosis (2 patients), polymyalgia rheumatica (2 patients), and urticaria (2 patients). One patient each was diagnosed with Crohn's disease, autoimmune gastritis, collagenous colitis, hypophysitis, and sarcoidosis. Investigating 100 patients with polyglandular syndrome and autoimmune thyroid disease for the occurrence of autoantibodies associated with AIH, we identified AIH-associated antibodies only in 1 patient. CONCLUSIONS Concurrent autoimmune diseases are common in patients with AIH and mirror the full range of known autoimmune diseases. Therefore, an extended diagnostic screening for accumulating autoimmune diseases, especially autoimmune thyroiditis, seems reasonable in patients with AIH.
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