2291 Drug-Induced Autoimmune Hepatitis Secondary to Infliximab

Abstract

INTRODUCTION: The increased utilization of Infliximab therapy has produced a small number of reported cases associating Infliximab with varying patterns of drug-induced liver injury. We present a rare case report of drug-induced autoimmune hepatitis that embodies a realistic presentation of a potentially underreported liver injury pattern that can occur following the induction of Infliximab therapy. CASE DESCRIPTION/METHODS: A 36 yo female with a PMHx significant for Crohn’s Disease, HTN and chronic alcohol abuse was admitted for generalized body aches, right upper quadrant abdominal pain, and shortness of breath. The patient described a recent increase to her alcohol consumption from 48 to 120 oz of beer daily for the last two weeks. The patient otherwise denied: smoking tobacco, illicit drugs, and naturopathic or over the counter medications. Physical examination revealed jaundice and tenderness to the RUQ of the patient’s abdomen. No evidence of ascites, palmar erythema, spider angiomata or protein malnutrition were present. Lab Findings revealed: AST/ALT: 1135/175, T. Bili: 10.9, AP: 230, Albumin: 2.7, Platelets: 233, INR: 1.1. The patient’s lab findings and subjective history validated continued concern for alcoholic hepatitis. Viral hepatitis serologies and autoimmune markers were collected and produced negative results except for a positive Anti-Nuclear Ab; ANA Titer: 1:2560. A RUQ Ultrasound with Doppler revealed hepatomegaly without signs of cirrhosis. Histopathologic results from biopsy revealed florid lymphoplasmacytic portal inflammation, stage 2-3 with periportal/bridging fibrosis and was without steatosis or steatohepatitis; findings consistent with the diagnosis of autoimmune hepatitis and drug induced liver injury. DISCUSSION: A detailed review of the patient’s medications revealed Infliximab infusions were initiated 5 months prior ,with the most recent being 3 weeks before presentation. The patient had no new medication exposures. Despite an initial concern for alcoholic hepatitis, the patient’s biopsy results showed no evidence of an alcoholic liver injury pattern. The positive ANA, histopathology, favorable response to infliximab withdrawal followed by steroid induced immunosuppression was consistent with the diagnosis of drug-induced autoimmune hepatitis (DIAIH). This case suggests patients receiving Infliximab therapy with elevations in liver function tests require thorough evaluation and strong consideration of biopsy for appropriate diagnosis.