S2601 A Curious Case of Transient Autoimmune Hepatitis

Abstract

INTRODUCTION: Autoimmune Hepatitis (AIH) is a rare disease among human immunodeficiency virus (HIV) infected individuals due to their impaired immune system. Opportunistic hepatotropic viruses such as cytomegalovirus (CMV) have been described to trigger AIH. We report a case of a young male with suspected AIH who was ultimately diagnosed with HIV and disseminated CMV. There have been reports of CMV infection triggering AIH and awareness of the association between CMV and AIH is important as the clinical presentation of these entities may overlap ultimately resulting in erroneous diagnoses and management in an already immunocompromised population. CASE DESCRIPTION/METHODS: A 34 year-old-male who presented for evaluation of chronically elevated liver enzymes. He referred no significant symptoms. Denied illicit drug and alcohol use. Liver workup with negative hepatitis panel, positive ASMA 1:160 with elevated IgG of 2174 md/dL. Also found with acute HIV. During follow-up visit patient reported chronic watery diarrheas. He underwent liver biopsy due to suspected AIH with findings of one hepatocyte with an inclusion body consistent with CMV. In addition, pericellular fibrosis with early bridging fibrosis with increase in plasma cells suggestive of AIH. Laboratories with positive CMV IgG and CMV DNA quantitative of 75944 IU/ml. Sigmoidoscopy with diffuse, friable, erythematous lesions from 40 cm to rectum. Biopsies consistent with CMV colitis. Later he developed CMV retinitis. He was started on ganciclovir and HAART therapy with normalization of liver enzymes. DISCUSSION: AIH is an uncommon disease with a global incidence that ranges from 0.7 to 2 per 100,000 population per year. The incidence of AIH in HIV patients is even lower and this diagnosis is often not suspected as it is counterintuitive in the setting of impaired immune system. Most AIH cases reported in HIV patients are associated with the immune reconstitution phase and rarely as a consequence of infection with opportunistic hepatotropic viruses as appeared to be in our case. The mechanism of AIH overlapping with CMV is believed to be molecular mimicry via cross reactivity between CMV exons and cytochrome CYP2D6. This case illustrates the importance of considering hepatotropic viruses when AIH is suspected given their potential for triggering AIH. The treatment strategies of these entities are vastly different highlighting the importance of ensuring a correct diagnosis at time of presentation.Figure 1.: Hepatocyte with inclusion consistent with Cytomegalovirus.Figure 2.: Diffuse friable erythematous lesions consistent with Cytomegalovirus colitis.Figure 3.: Focal acute colitis with areas of mucosal hemorrhage and Cytomegalovirus inclusions.