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Contributing awareness of autoimmune hepatitis in HIV patients. AIDS 2019; 33:2103-2105. [PMID: 31577575 DOI: 10.1097/qad.0000000000002299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chaiteerakij R, Sanpawat A, Avihingsanon A, Treeprasertsuk S. Autoimmune hepatitis in human immunodeficiency virus-infected patients: A case series and review of the literature. World J Gastroenterol 2019; 25:5388-5402. [PMID: 31558881 PMCID: PMC6761245 DOI: 10.3748/wjg.v25.i35.5388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/14/2019] [Accepted: 08/24/2019] [Indexed: 02/06/2023] Open
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.
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Affiliation(s)
- Roongruedee Chaiteerakij
- 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
| | - Sombat Treeprasertsuk
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
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Mubder M, Azab M, Jayaraj M, Cross C, Lankarani D, Dhindsa B, Pan JJ, Ohning G. Autoimmune hepatitis in patients with human immunodeficiency virus infection: A systematic review of the published literature. Medicine (Baltimore) 2019; 98:e17094. [PMID: 31517833 PMCID: PMC6750342 DOI: 10.1097/md.0000000000017094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Liver disease in patients with HIV is common and typically has complex and multifactorial presentations that represent a major cause of morbidity and mortality. Autoimmune hepatitis (AIH) is rarely reported in patient with HIV and the disease course and clinical outcomes for treatment have not been well characterized. We are aiming to determine the patient characteristics, disease prevalence, and treatment outcomes from published articles of patients with HIV and AIH. METHOD A systematic search of PubMed, Web of Science, and Google Scholar through February 20, 2019 identified 15 studies that reported the outcomes of AIH in patients with HIV. Because of the small sample sizes and skewed distributions, resampling tests of mean differences using permutation distributions (MAXn = 10,000 permutations) were utilized; analyses were performed using R (v. 3.5.1). Categorical differences were calculated using Fisher exact test for odds ratio = 1 (equal odds), and Cramer V was calculated for effect size; analyses were completed in SPSS (v. 25). RESULTS By reviewing 15 studies reporting a total of 35 patients with AIH and HIV, male patients were found to have significantly higher aspartate transaminase and alanine transaminase levels at time of diagnosis. No other significant findings identified. The CD4 count and viral load did not show significant correlation with AIH diagnosis or its prognosis. All patients but one who presented with severe immune deficiency and responded to highly active anti-retroviral therapy received immunosuppressive treatment without side effects and achieved remission except 2 lost to follow-up and 3 expired. CONCLUSION Although rare, but AIH can develop in patients with HIV and physicians should consider it in the differential diagnosis for HIV patients presented with abnormal liver function tests, especially after excluding hepatitis C virus and drug-induced liver injury.Patients with immune deficiency disorders who present with AIH can be treated safely with steroid either as monotherapy or in combination with another immune suppressant therapy.
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Affiliation(s)
- Mohamad Mubder
- Department of Internal Medicine, University of Nevada, Las Vegas, NV
| | - Mohamed Azab
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, CA
| | - Mahendran Jayaraj
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nevada, Las Vegas, NV
| | | | - Daisy Lankarani
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nevada, Las Vegas, NV
| | - Banreet Dhindsa
- Department of Internal Medicine, University of Nevada, Las Vegas, NV
| | - Jen-Jung Pan
- Department of Internal medicine, Division of Gastroenterology and Hepatology, University of Arizona-College of Medicine, Phoenix, AZ
| | - Gordon Ohning
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nevada, Las Vegas, NV
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4
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Autoimmune Hepatitis (AIH) in Acquired Immune Deficiency Syndrome (AIDS): A Case Report and Review of Literature. Case Reports Hepatol 2019; 2019:5326428. [PMID: 31281688 PMCID: PMC6590560 DOI: 10.1155/2019/5326428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/22/2019] [Accepted: 05/02/2019] [Indexed: 11/23/2022] Open
Abstract
The common causes of abnormal liver chemistries in human immunodeficiency virus (HIV) infected patients are multifactorial. Diagnosis of autoimmune hepatitis (AIH) in HIV infected patients is intriguing but data is scarce. Unmasking of AIH during immune reconstitution in HIV patients after starting antiretroviral therapy is reported but not with advanced acquired immunodeficiency syndrome (AIDS). Here we present a fascinating case of 32-year-old African-American man with advanced AIDS who presented with elevated transaminases. He was diagnosed with AIH before starting antiretroviral therapy and successfully treated with prednisolone and azathioprine with antiretroviral therapy despite very low CD4 count.
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Rodrigues EM, Fernandes R, Susin R, Fior B. Immune reconstitution inflammatory syndrome as a cause of autoimmune hepatitis and acute liver failure. Rev Bras Ter Intensiva 2018; 29:382-385. [PMID: 29044307 PMCID: PMC5632982 DOI: 10.5935/0103-507x.20170053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/02/2017] [Indexed: 12/18/2022] Open
Abstract
Acute liver failure is a rare syndrome with high mortality and is often diagnosed
late. Intensivist physicians play fundamental roles in the diagnostic suspicion
and the management of the multiple-organic dysfunctions characteristic of this
entity. Immune reconstitution inflammatory syndrome is an entity that is
characterized by the paradoxical worsening of the patient's previous condition,
after the initiation of antiretrovirals, triggered against either pathogens
present in the host or autoantigens. Autoimmune hepatitis has recently been
described as one of these autoimmune manifestations. The authors report the
first case with evolution to acute liver failure and death within a few days
after the development of encephalopathy, review the cases of autoimmune
hepatitis described and comment on the therapeutic possibilities in this
context.
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Affiliation(s)
- Edison Moraes Rodrigues
- Grupo de Transplante Hepático, Irmandade da Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva de Transplantes, Hospital Dom Vicente Scherer, Irmandade da Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil.,Rede Institucional de Pesquisa e Inovação em Medicina Intensiva, Irmandade da Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil
| | - Rogério Fernandes
- Grupo de Transplante Hepático, Irmandade da Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil
| | - Ruth Susin
- Unidade de Terapia Intensiva de Transplantes, Hospital Dom Vicente Scherer, Irmandade da Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil
| | - Bárbara Fior
- Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
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Ofori E, Ramai D, Ona MA, Reddy M. Autoimmune hepatitis in the setting of human immunodeficiency virus infection: A case series. World J Hepatol 2017; 9:1367-1371. [PMID: 29359021 PMCID: PMC5756727 DOI: 10.4254/wjh.v9.i36.1367] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/16/2017] [Accepted: 12/06/2017] [Indexed: 02/06/2023] Open
Abstract
Liver injury in the setting of human immunodeficiency virus (HIV) infection is more commonly attributed to viral hepatitis or highly active antiretroviral treatment (HAART) toxicity. The severity of liver injury is an important cause of morbidity and mortality. The emergence of autoimmune diseases, particularly autoimmune hepatitis (AIH) in the setting of HIV infection, is rare. Previous reports indicate that elevated liver enzymes are a common denominator amongst these patients. We present two patients with HIV infection, on HAART, with virological suppression. Both patients presented with elevated liver enzymes, and following liver biopsies, were diagnosed with AIH. The clinical course of these patients underscore the therapeutic value of corticosteroids, and in some cases, addition of immunosuppression for AIH treatment.
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Affiliation(s)
- Emmanuel Ofori
- Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY 11201, United States
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY 11201, United States.
| | - Mel A Ona
- Division of Advanced Endoscopy, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY 11201, United States
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Noreña I, Morantes-Caballero JA, Garcés A, Gómez BJ, Rodríguez G, Saavedra C, Otero W. Autoimmune hepatitis in human immunodeficiency virus infection: Case report and literature review. World J Clin Infect Dis 2017; 7:50-57. [DOI: 10.5495/wjcid.v7.i4.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/02/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
The infection due to human immunodeficiency virus (HIV) is characterized by the progressive reduction of CD4+ T lymphocytes and the compromise of other cell lines of the immune system, resulting in immunosuppression. In this context, autoimmune diseases could be considered contradictory, however, cases of autoimmune diseases during this infection have been described, including autoimmune hepatitis (AIH), which is uncommon and has few case reports within medical literature, none of them from Latin America. In this case report where a patient with an HIV infection on combined antiretroviral treatment developed acute elevation of transaminases, hyperbilirubinemia, and deterioration in hepatic synthetic function. Although initially an antiretroviral drug-induced liver injury was suspected, during the study a diagnosis of autoimmune hepatitis was proven, which required treatment with corticosteroid and azathioprine, obtaining a satisfactory response and managing to continue the antiretroviral therapy. Autoimmune diseases in HIV infection must be taken into account. In the case of hepatitis in patients with HIV on antiretroviral treatment, the differentiation between viral hepatitis caused by autoimmune diseases or medications is essential to establish an adequate treatment, and avoid the suspension of the antiretroviral therapy.
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Affiliation(s)
- Ivan Noreña
- Infectious Diseases Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Jairo A Morantes-Caballero
- Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Andrés Garcés
- Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Brian José Gómez
- Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Gabriel Rodríguez
- Infectious Diseases Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Carlos Saavedra
- Infectious Diseases Section, 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
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9
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Murunga E, Andersson M, Rensburg CV. Autoimmune hepatitis: a manifestation of immune reconstitution inflammatory syndrome in HIV infected patients? Scand J Gastroenterol 2016; 51:814-8. [PMID: 27000683 DOI: 10.3109/00365521.2016.1157888] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe a case series of patients presenting with autoimmune hepatitis after initiation of antiretroviral therapy. MATERIALS AND METHODS The demographics, clinical and laboratory features, and therapeutic response of HIV-infected patients on antiretroviral therapy presenting to our Division between November 2011 and November 2014 with elevated liver enzymes, were analysed. RESULTS Nine patients with elevated liver enzymes, immunoglobulin G and autoimmune markers in keeping with autoimmune hepatitis were identified. All were anti-hepatitis C virus negative. One patient was hepatitis B surface antigen positive but his hepatitis B viral load was undetectable. All patients denied using any traditional herbal remedies. Liver histology was consistent with autoimmune hepatitis showing interface hepatitis and infiltrates of lymphocytes and plasma cells. Diagnosis was made according to the Autoimmune Hepatitis Group Scoring Systems. All patients were started on 15-20 mg of oral prednisone with clinical and biochemical improvement after 1-6 weeks. CONCLUSIONS Immune reconstitution related autoimmune hepatitis should be considered in the differential diagnosis of hepatitis in the HIV-infected patient on antiretroviral therapy. Liver biopsy should be performed and the diagnosis confirmed using scoring systems developed by the Autoimmune Hepatitis Group. Timely treatment with prednisone and other agents for autoimmune hepatitis is indicated, and can be lifesaving in acute liver failure.
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Affiliation(s)
- Eric Murunga
- a Division of Gastroenterology , Stellenbosch University Medical School , Cape Town , South Africa
| | - Monique Andersson
- b Division of Infectious Diseases , Stellenbosch University Medical School , Cape Town , South Africa
| | - Christo van Rensburg
- a Division of Gastroenterology , Stellenbosch University Medical School , Cape Town , South Africa
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Acquired hemophilia A in the HIV-infected patient: a case report and literature review. Blood Coagul Fibrinolysis 2015; 26:207-10. [PMID: 25255240 DOI: 10.1097/mbc.0000000000000207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acquired hemophilia A is a rare bleeding disorder caused by autoantibodies against factor VIII (FVIII). Spontaneous bleeding in the various sites and severity is the most common clinical presentation. Here, we report a 74-year-old Thai woman with HIV infection who presented with spontaneous ecchymoses. The laboratory revealed isolated activated partial thromboplastin time prolongation with low FVIII activity and a presence of FVIII inhibitor. She was diagnosed with acquired hemophilia A. Corticosteroid monotherapy was the treatment regimen for inhibitor eradication. We demonstrate the clinical course of the rare condition and review the relevant literature.
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Autoimmune diseases-related arthritis in HIV-infected patients in the era of highly active antiretroviral therapy. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 48:130-6. [DOI: 10.1016/j.jmii.2013.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 08/01/2013] [Accepted: 08/09/2013] [Indexed: 11/22/2022]
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12
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Immune reconstitution disorders in patients with HIV infection: from pathogenesis to prevention and treatment. Curr HIV/AIDS Rep 2015; 11:223-32. [PMID: 24950732 DOI: 10.1007/s11904-014-0213-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
An immune reconstitution disorder occurs in up to 40 % of severely immunodeficient HIV patients who commence antiretroviral therapy (ART), with an immune reconstitution inflammatory syndrome (IRIS) being encountered most commonly. Differences in the immunopathogenesis of an IRIS associated with different types of pathogen have become apparent but common features have also been defined. These include severe immunodeficiency prior to commencing ART associated with a high pathogen load and 'compensatory' immune responses, particularly innate immune responses, which inadequately control the pathogen and increase the risk of immunopathology as the immune system recovers on ART. Prevention of an IRIS may be achieved by optimising therapy for opportunistic infections before ART is commenced, delaying ART or using immunomodulatory therapy to prevent or suppress the immune response that causes the immunopathology. However, further clinical studies are required to examine these options in a systematic manner for the various types of IRIS.
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Moura MC, Pereira E, Braz V, Eloy C, Lopes J, Carneiro F, Araújo JP. Autoimmune hepatitis in a patient infected by HIV-1 and under highly active antiretroviral treatment: Case report and literature review. World J Immunol 2014; 4:194-198. [DOI: 10.5411/wji.v4.i3.194] [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] [Received: 07/06/2014] [Revised: 10/12/2014] [Accepted: 10/29/2014] [Indexed: 02/05/2023] Open
Abstract
Liver disease has recently been described as an important cause of morbidity and mortality in patients infected with human immunodeficiency virus (HIV). Liver test changes are useful surrogates of the burden of liver disease. Previous studies have shown that transaminase elevations are frequent among these patients. The cause of those changes is harder to establish in HIV-patients. We present a 61-year-old caucasian male, diagnosed with HIV type 1 infection since 1998, under highly active antiretroviral treatment (HAART), with virological suppression and immunological recovery. He presented in a follow-up laboratory workup high values of transaminases, arthralgia at the hip joints and hepatomegaly. Liver function tests were normal. The antibodies to hepatitis viruses were negative. However, autoimmune study and liver biopsy were compatible with autoimmune hepatitis (AIH). The AIH is a rare diagnosis in HIV-infected patients perhaps because the elevation of transaminases and changes in liver function tests are often associated to HAART or to other possible liver diseases, namely viral hepatitis and non-alcoholic steatohepatitis. The diagnosis may be underestimated. There are no specific recommendations available for the treatment of HIV-associated AIH although the immunosupression with slower tapering seems the most reasonable approach.
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Caplan M, Trivedi A, McLaughlin M, Hebou A, Kleiner DE, Heller T, Morse CG. Primary Biliary Cirrhosis Overlapping with Autoimmune Hepatitis in an HIV-Infected Patient on Antiretroviral Therapy. JOURNAL OF INTERDISCIPLINARY HISTOPATHOLOGY 2013; 1:270-273. [PMID: 26807302 PMCID: PMC4723101 DOI: 10.5455/jihp.20130624104921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Liver disease in HIV-infected patients is complex and multifactorial. Drug toxicity and infections are common causes of elevations in liver-associated enzymes. Immune reconstitution and unmasking of autoimmune disease may also play a role, particularly in the era of effective combination antiretroviral therapy. In this case report, we describe the first reported biopsy-confirmed case of autoimmune hepatitis and primary biliary cirrhosis overlap syndrome presenting in an HIV-infected patient following initiation of antiretroviral therapy.
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Affiliation(s)
- Margaret Caplan
- Clinical Research Directorate/CMRP, SAIC-Frederick, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Apurva Trivedi
- Liver Diseases Branch, National Institute of Diabetes, Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - Mary McLaughlin
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | | | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes, Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - Caryn G Morse
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
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