Chondroitin Sulphate: Unmasking Autoimmune Hepatitis

Abstract

Auto-immune hepatitis is a chronic liver condition characterized by the presence of immunologic features. Triggers for auto-immune hepatitis are hypothesized to be environmental factors, viruses, drugs and herbal supplements. Herein we present a case of auto-immune hepatitis unmasked by a chondroitin sulphate supplement. A 64 year old woman with persistent mildly elevated liver function tests (LFT's); Aspartate aminotransferase (AST) 36-114 U/L, alanine aminotransferase (ALT) 24-86 U/L and minimally elevated anti-nuclear antibody (ANA) and anti-smooth muscle antibody(ASMA)titers (1:40) was found to have a sudden increase in her LFT's during her 8th year of follow up. AST was 543 U/L, ALT 650 U/L, alkaline phosphatase 139 U/L, total bilirubin 1.4mg/dL, gamma-glutamyl transferase 285 U/L. One month prior to the office visit, the patient started taking a chondroitin supplement for knee osteoarthritis. Hepatitis serology, iron studies and auto-immune hepatitis workup was repeated which revealed negative viral hepatitis serology, normal iron studies and an increase in her anti-nuclear antibody titer(ANA) 1:2560, anti-smooth muscle antibody(ASMA) titer 1:160 and negative AMA. Abdominal ultrasound revealed mild coarse echotexture of the liver. Liver biopsy was performed which was suggestive of auto-immune hepatitis with moderate activity and cirrhosis (fig.1-2). International AIH score was 7 consistent with a definite diagnosis of AIH. Treatment with azathioprine and prednisone was started. In our patient the history of mildly elevated LFT's and positive ANA and ASMA indicate that the patient had a history of mild undiagnosed auto-immune hepatitis however the consumption of chondroitin sulphate unmasked her disease as evident by the sudden increase in LFT's, ANA and ASMA. Herbal preparations and supplements are often thought of as natural alternative remedies to medication without adverse effects. Chondroitin sulfate is a sulphated glycosaminoglycan and has become a widely used dietary supplement for treatment of osteoarthritis. Although it is a generally well tolerated dietary supplement, chondroitin sulphate has been reported to cause drug-induced liver injury in patients with chronic liver disease and even liver injury mimicking auto-immune hepatitis as reported previously. Supplements containing chondroitin sulphate may not be suitable for patients with chronic liver disease and may be associated with auto-immune hepatitis. Further investigation is warranted.Figure: Liver biopsy 20x. Portal triad with inflammation, interface hepatitis.Figure: Liver biopsy 40x. Mixed infiltrate plasma cells and lymphocytes.Figure: Trichrome stains showing bridging fibrosis with nodules. 10x.