S2981 Drug-Induced Autoimmune-Like Hepatitis Due to HemoHIM in a 28-Year Old Pregnant Woman

Abstract

Introduction: Drug-induced autoimmune-like hepatitis (DIAIH) is a pathologic immune response against proteins in the liver that can be triggered in susceptible individuals by drugs or herbal remedies. While any supplement can cause idiosyncratic hepatotoxicity, up to 16% of drug-induced liver injuries are attributable to herbal supplements. To date, there are still limited data on herbal medicine-related hepatotoxicity. This topic is particularly understudied in pregnant patients, with most current clinical information coming from case reports. While use of supplements is common during pregnancy, there is still limited information regarding their safety. Case Description/Methods: A previously healthy G4P2A1 28-year-old presented at 5 weeks of pregnancy with right upper quadrant pain and fevers, and was presumed to have acute cholecystitis resulting in a laparoscopic cholecystectomy. Despite this, her liver enzymes continued to worsen (AST 2893, ALT 2664, TBili 2.6, Alk Phos 460, INR 1.3). The patient also had laboratory evidence of AIH including Anti-Mi+ 34.5, U1-RNP/RNA-A68 2.4, Chromatin Abs 1.6. She underwent liver biopsy showing drug-induced liver injury and autoimmune hepatitis (AIH). Given that AIH often presents during pregnancy, it was unclear if this presentation represented DIAIH or AIH. Notably, the patient had recently started taking an herbal supplement with purported immune support called HemoHIM that was thought to be a possible driver of DIAIH, The supplement was discontinued and she was started on a 60mg prednisolone with subsequent clinical and laboratory improvement. Despite improvement, the patient suffered spontaneous abortion early in the treatment course and in retrospect underwent unnecessary cholecystectomy. Given concern for possible AIH and slow normalization of LFTs, she was started on azathioprine, but self-discontinued after 7 months. Her liver enzymes remained stable 6 months later; supporting a diagnosis of DIAIH due to HemoHIM rather than AIH which would have likely rebounded with such early treatment withdrawal. Discussion: While DIAILH is an underreported disease in pregnant women this case demonstrates the importance of early diagnosis and treatment. Additionally, it illustrates he challenges in distinguishing between DAILH and AIH especially in patients taking herbal supplements.