Seronegative Autoimmune Hepatitis A Clinically Challenging Difficult Diagnosis

The progress of autoimmune hepatitis research and future challenges

Autoimmune hepatitis (AIH) is a chronic liver inflammatory disease with various immune system manifestations, showing a global trend of increased prevalence. AIH is diagnosed through histological abnormalities, clinical manifestations, and biochemical indicators. The biochemical markers involve interfacial hepatitis, transaminase abnormalities, positive autoantibodies, etc. Although AIH pathogenesis is unclear, gene mutations and immunological factors could be the leading factors. AIH usually presents as a chronic liver disease and sometimes as acute hepatitis, making it challenging to distinguish it from drug-related hepatitis due to similar clinical symptoms. Normalizing transaminases and serum IgG levels is essential in assessing the remission status of AIH treatment. Glucocorticoids and azathioprine are the first-line AIH treatment, with lifelong maintenance therapy in some patients. The quality of life and survival can be improved after appropriate treatment. However, certain limitations jeopardize the quality of treatment, including long treatment cycles, side effects, poor patient compliance, and inability to inhibit liver fibrosis and cirrhosis. Accurate AIH animal models will help us understand the pathophysiology of the disease while providing fresh perspectives for avoiding and treating AIH. This review will help us understand AIH better, from the cellular and molecular causes to the clinical features, and will provide insight into new therapy techniques with fewer side effects.

Seronegative Autoimmune Hepatitis: A Rare Manifestation of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the coronavirus pandemic in 2019, commonly causes hepatic dysfunction. Liver injury ranges from mildly elevated liver enzymes to fulminant liver failure. Interestingly, there are cases that suggest a relationship between autoimmune hepatitis (AIH) in patients who either contracted coronavirus disease in 2019 (COVID-19) or were vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We present a case of a 39-year-old female without a significant past medical history who presented with two weeks of jaundice, abdominal pain, nausea, and diarrhea. She had significantly elevated liver enzymes and conjugated hyperbilirubinemia. She also tested positive for SARS-CoV-2 but denied any respiratory symptoms; her vaccination status was up to date. She denied taking hepatotoxic agents, and the workup was negative for acute viral hepatitis. The F-actin antibody level was 22 units, but serum immunoglobulin (IgG), anti-nuclear (ANA), anti-smooth muscle, anti-mitochondrial, anti-liver/kidney microsomal-1, anti-soluble liver antigen, and anti-neutrophil cytoplasmic antibodies levels were not elevated. Computerized tomography of the abdomen and pelvis revealed hepatic hemangiomas. Eventually, a liver biopsy was performed, and histology showed active lymphoplasmacytic hepatitis with prominent regenerative changes and areas of confluent necrosis. The histologic findings, along with the patient's clinical course, were suggestive of autoimmune hepatitis. The patient was started on systemic steroids with an improvement of abdominal pain and jaundice, as well as an improvement of her liver chemical profile. She was discharged with plans for hepatology clinic follow-up. Here, we present a rare case of seronegative AIH in a patient with a recent COVID-19 infection and discuss the potential underlying mechanism. We call for further investigation into the relationship between autoimmune dysfunction and COVID-19, as well as the pathophysiology behind it. Analyzing how the virus causes autoimmune dysfunction may allow clinicians to more effectively treat patients suffering from sequelae of COVID-19 infection, and it is important not to exclude autoimmune hepatitis from the differential based on the initial autoimmune workup.

Seronegative Autoimmune Hepatitis

Autoimmune hepatitis (AIH) is a relatively rare liver disease with varying worldwide incidence of from 0.7 to 2 per 100,000 people. It is characterized by the presence of auto-antibodies. However, an average of 10% of AIH cases have AIH symptoms and pathology but lack autoimmune serology. For such seronegative AIH (snAIH) cases, there is currently no established diagnostic algorithm for diagnosis. and improper or delayed diagnosis of snAIH can lead to no or inappropriate treatment that results in progression to fulminant hepatitis or cirrhosis. This review aims to review the current literature and to present an update of seronegative autoimmune hepatitis, including its pathophysiology, clinical presentation, methods of diagnosis, and treatment in order to increase awareness and emphasize the necessity for timely management.

Clinical Characteristics of Autoimmune Hepatitis in a Middle Eastern Population: A Tertiary Care Center Experience

Autoimmune hepatitis (AIH) is an immune-mediated inflammatory liver disease of uncertain cause, and its manifestations appear to vary by race and ethnicity. The literature on AIH in the Middle East, including Jordan, is scarce; therefore, this study aimed to determine the clinical characteristics of AIH in an understudied population. This retrospective chart review study was conducted on AIH patients who presented to Jordan University Hospital over a seven-year period (2014-2020). Retrieved data included sociodemographics, liver function tests, autoimmune serologic markers, viral hepatitis serology, findings on liver biopsies, treatment regimens, post-therapy outcomes and treatment-related complications. The total number of AIH patients included in the study was 30, divided as follows: type 1 AIH (n = 17, 56.7%), type 2 AIH (n = 2, 6.7%), seronegative AIH (n = 9, 30.0%), and two patients who had AIH-primary biliary cirrhosis overlap syndrome (6.7%). The mean age at diagnosis was 44 years (standard deviation: 17 years), with a female predominance (n = 25, 83.3%). Acute presentation was seen among 18 patients (60.0%). Mild to moderate fibrosis (F1 and F2 on METAVIR scoring system) without cirrhosis was observed among patients who underwent liver biopsies (10/19, 52.6%). The majority of patients (73.3%) were initially treated with prednisone, with azathioprine combination in 16.7% of the patients. At 6 months post initial treatment, twenty patients (66.7%) achieved biochemical remission, four patients had incomplete response, two patients failed to improve (one died during the induction of remission period due to AIH-related complications), and four patients were lost to follow-up. This study provided an updated overview of AIH in Jordan. The results showed typical female predominance, and interestingly high rates of acute presentation and seronegative disease. Future longitudinal studies are recommended to address the nature and long-term prognosis of AIH in Jordan.

A Novel Presentation of Autoimmune Hepatitis with IgG1 Elevation

Autoimmune hepatitis (AIH) is a common and debilitating pathology that has acute, subacute, and chronic presentation, requiring prompt diagnosis and early intervention. Several serologic markers are found to be associated with the pathogenesis and progression of autoimmune hepatitis, most notably antinuclear antibodies and anti-smooth muscle antibodies [Front Immunol. 2018;9:609]. In addition, AIH is also characterized by the elevation of gamma globulin levels, mainly immunoglobulin G (IgG) [World J Gastroenterol. 2015;21(1):60-83]. Although the literature has well established the presence of increased IgG levels in AIH, few studies have evaluated the subtypes of IgG and their differential levels associated with AIH. Here, we present a rare case of AIH that lacks the common serologic markers but instead reveals an elevation in IgG1 level. Our patient was subsequently placed on corticosteroids, and her symptoms quickly resolved. We intend to introduce this case to the medical community in the hope of aiding in the proper diagnosis and timely intervention of subsequent cases with similar presentations.

Doxycycline-induced cholestatic liver injury

Doxycycline-induced liver injury is a rare phenomenon, with an unclear clinical course and etiopathogenesis. The onset of injury may be acute-to-subacute, with a pattern ranging from hepatocellular or cholestatic to mixed, and it often lasts up to several weeks. We present a case of cholestatic liver injury secondary to doxycycline use in a middle-aged woman. In patients with a history of doxycycline exposure and subsequent hepatic injury, an adverse drug reaction due to doxycycline should remain on the differential, and immediate removal of the offending agent with close monitoring of the clinical condition should be pursued.

IgG4-associated autoimmune hepatitis and cholangitis: A relatively novel entity to consider in cases of seronegative autoimmune hepatitis

A 49-year-old woman with no inflammatory bowel disease history presented to our clinic with abnormal liver function tests and right upper quadrant abdominal pain. Blood tests revealed a mixed pattern of liver injury. Abdominal magnetic resonance imaging demonstrated hepatomegaly with periportal edema and hyper-enhancing bile ducts without any sign of biliary obstruction or stricturing. Screening for viral hepatitis and autoimmune liver diseases was negative. An elevated immunoglobulin G (IgG) level suggested the possibility of autoimmune hepatitis (AIH), and a biopsy confirmed the presence of severe interface hepatitis with necrotic areas and focal lymphoid nodular formation. IgG4 staining revealed marked IgG4-positive plasma cell infiltration. A diagnosis of IgG4-associated seronegative AIH was made, and the patient was started on prednisone and azathioprine, with rapid resolution of the enzyme abnormalities. This clinical vignette highlights the potential challenges in establishing a diagnosis of IgG4-associated AIH and cholangitis, as demonstrated by the importance of confirmatory histopathology. Clinicians should maintain a high index of suspicion when confronted with a mixed pattern of liver injury with elevated immunoglobulins but seronegative autoimmune markers.

Autoimmune liver disease following acute hepatitis A infection

A male patient in his late 30s presented to our outpatient clinic at Mortimer Market Centre with worsening liver transaminases tests 2 months after a resolved acute hepatitis A infection. A diagnosis of parainfectious autoimmune-like hepatitis phenomena was made based on the history, laboratory and histological features.

A Case of Acute Autoimmune Hepatitis Superimposed on Chronic Hepatitis B Infection

Autoimmune hepatitis has been associated with chronic HCV infection, but there are only few cases reported of HBV infection as a possible trigger. We present a case of a young male who was diagnosed with acute autoimmune hepatitis superimposed on existent chronic HBV infection. A 30-year-old Hispanic male with no past medical history presented to the hospital with complaints of few days of generalized weakness. Laboratory findings were significant for elevated liver enzymes: AST, 1164 U/L; ALT, 1461 U/L; total bilirubin, 2 MG/DL; and alkaline phosphatase, 75 IU/L. Extensive workup was done to find the etiology for elevated liver enzymes. Only blood work that came back positive was for chronic HBV infection and elevated immunoglobulin G (IgG) level 1937 mg/dL. HBV viral load was 42,900,000 IU/mL. The patient was started on tenofovir 300 mg daily. Liver biopsy was done which was consistent with autoimmune hepatitis. Prednisone 60 mg daily was started. Six months later, blood work showed completely normal liver enzymes and total IgG. Hepatotropic viruses have been proposed as triggering factors for several autoimmune diseases. There are theories suggesting that similarity in viral epitope and self-proteins expression on liver cells' surface causes a cross-reactive immunologic response and possible viral-induced autoimmune hepatitis.