A Case of Over-the-Counter, Drug-Induced Autoimmune Hepatitis: Immunohistochemical and Electron Microscopic Studies

Abstract

Introduction: In daily clinical practice, drug-induced liver injury(DILI) can always be a cause of liver injury in patients taking medications. Over-the-counter(OTC) drug: Pabron has been purchasing at the pharmacy in Japan, Thailand, Malaysia, and Chinese Taipei as a multi-component cold medicine. We desribed a case of DI-autoimmune hepatitis(AIH) from OTCdrug: Pabron gold®. Case description: A 64-year-old man sought treatment for common cold and was admitted for general fatigue and liver dysfunction. Blood test results included total bilirubin (T-bil), 2.4 mg/dL; direct bilirubin (D-bil), 1.4 mg/dL; AST, 1,244 IU/L; ALT 1,455 IU/L; ALP 1,242 IU/L; and γ-GTP 599, IU/L. Viral hepatitis serology was negative. Other relevant data included IgG level, 1,907 mg/dL; IgM, 95 mg/dL; ANA x80 (cut-off, < x40); ASMA x20 (cut-off, OTC, namely Pabron Gold®, prior to disease onset which was suspected as the cause of liver injury. A DI lymphocyte stimulation test for Pabron Gold® was positive, 2,447 cpm (503%) (< 179%). The liver biopsy revealed spotty necrosis and the accumulation of ceroid pigment in Kupffer cells around central vein, and piecemeal necrosis with multiple plasma cells around portal tracts. Moreover, the plasmocytic infiltration showed positive CD79a staining while negative CD20 staining. Ultrastructually, “cart-wheel” chromatin configuration in the nucleus was observed in some of plasma cells packing with a lot of rough-surfaced endoplasmic reticulum. Moreover, the characteristic granular osmiophilic materials and lipid droplet were observed in Kupffer cell. HLA typing test was HLA-DR4 positive. The score based on simplified criteria for autoimmune hepatitis diagnosis was 6, probable. With a persistent rise in aminotransaminase levels, the patient was started on steroids with predonine prescribed to control the hepatic inflammation. Discussion: This report is the first to describe a case of DI-AIH following the use of an over-the-counter drug. In fact, DI-AIH diagnosis represents a challenge to the clinician because neither histological nor clinical pathognomonic features of AIH exist. We described a case of OTC Pabron gold®-associated liver injury, diagnosed as DI-AIH, calling for caution in the use of OTC.