3170 Autoimmune Hepatitis in an Elderly Patient

Abstract

INTRODUCTION: Autoimmune hepatitis (AIH) is a chronic inflammatory disease associated with younger age and female predominance. While patients presenting ≥65 years has been described, these are based on small cohorts. 1,2 We present a case of an elderly man admitted with painless jaundice, found to have AIH. Given favorable prognosis if diagnosed and treated early, AIH is an important differential diagnosis regardless of age. CASE DESCRIPTION/METHODS: An 85-year old man presented with 5-week history of weakness. Physical exam revealed jaundice of the eyes and skin. Laboratory data revealed alanine transaminase (ALT) 173 IU/L, aspartate aminotransferase (AST) 258 IU/L, alkaline phosphatase 306 IU/L, total bilirubin 9.9 mg/dL, and serum albumin 2.7 g/dL. Abdominal CT revealed normal liver size and contour without biliary ductal dilatation. MRCP showed filling defect within distal common bile duct to the ampulla however ERCP did not identify filling defect and sphincterectomy did not reveal stone or sludge (Figure 1). Liver biopsy revealed interface and lobular hepatitis with abundant plasma cells and minimal bile duct damage (Figures 2 and 3). Anti smooth muscle antibody and immunoglobulin G (IgG) were elevated to 76 U and 2,875 mg/dL, respectively. Anti liver-kidney microsomal antibody IgG, viral hepatitis, anti nuclear antibody, and anti mitochondrial antibody studies were negative. The patient began Azathioprine and Prednisone and within 9 weeks, ALT and AST normalized with improved sense of well being. DISCUSSION: AIH reported in the elderly has been described, however onset <40 years is more common. 1 Thus, this diagnosis is often delayed in elderly patients. It has been suggested that AIH in the elderly may represent a less severe, indolent process, which presents clinically at a later age. Unlike other autoimmune processes, few differences in disease course have been described between younger and older patients. Compared to other etiologies of chronic liver disease, AIH carries an excellent prognosis once therapy is initiated using prednisone ± Azathioprine. Untreated, AIH carries a dismal prognosis, with 5 and 10-year survival reported to be 50% and 10%, respectively. 3